Private sector Xpert MTB/RIF scale-up:
successes and challenges of the
TBXpert social business projects
Aamir Khan, MD PhD
Executive Director, IRD
Imran Zafar, MBA, M.Sc.
CEO, CHS
Private providers and TB in Karachi
Private Sector TB REACH Projects
2011 - TB REACH 1 Karachi
• Verbal screening – private GP clinics and hospital OPDs
• Performance based incentives for screeners, community out-reach
2012 - TB REACH 2 Karachi, Dhaka
• Verbal screening at private laboratories, rapid TB testing on GeneXpert
2013 - TB REACH 3 and UNITAID TBXpert Karachi, Dhaka, Jakarta
• Social business delivery model to scale chest X-ray and GeneXpert testing
• Focused on lung health and diabetes, not just TB
• Verbal screening and referrals from GPs, hospital OPDs, private laboratories,
public hospitals, pharmacies
Susceptible TB (all forms) Case Notification
by Indus Hospital and IRD TB REACH Projects
Q4 2007- Q1 2015 Karachi
Indus Hospital
TB REACH Projects
Indus Hospital Treatment Success Rate
TB REACH Projects Treatment Success Rate
2500
100%
90%
2000
80%
70%
1500
60%
50%
1000
40%
30%
500
20%
10%
0
0%
Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1
2007
2008
2009
2010
2011
2012
2013
2014
2015
TBXpert – TB REACH PPM -Social Business
Project
75 GeneXpert machines
Up to 450,000 cartridges
~USD 6 million
TB REACH wave3: USD 3 million
TBXpert – TB REACH PPM -Social Business
Model
Verbal Screening
at Private Clinic
or Public Hospital
Testing at Social Business Screening Center
USD 3-5
Treatment at
Private GP Clinic
or Public Hospital
Free
Free
USD 2-5
USD 0.5
Social business support to major public hospitals
to scale up GeneXpert testing in Karachi, Dhaka,
Jakarta
1. Install a GeneXpert machine at a designated public hospital
• Provide reagents, GeneXpert cartridges and maintenance; uninterrupted power
supply in Karachi
2. Develop referral network in the surrounding area
• Private laboratories, GP clinics and small hospitals
3. Conduct verbal screening within public hospital
• Chest clinics, out-patient-departments, in-patient wards, other sites
4. Ensure quality sputum and testing
• instructed sputum submission, sample transport, processing , low error rates on
GeneXpert
5. Support drug-susceptible patient care
• Reporting test results to patients, counseling, NTP notification, treatment
compliance.
6. Direct linkages with PMDT sites
• referral of MTB/RIF positive TB cases to PMDT sites, including transport support
TBXpert Screening Algorithms
Q3 2013 – Q4 2014 Karachi, Pakistan
300000
250000
Multiple Algorithms
Verbal Screening
to GeneXpert
3000000
WHO Algorithm 2B
Chest X-ray not available, Xpert MTB/RIF available
WHO Algorithm 2D
Chest X-ray and Xpert MTB/RIF available
2500000
200000
2000000
150000
1500000
1st Screening
Center launched
GP Referral
Strategy
launched
100000
1000000
50000
500000
0
5857
5741
2666
1526
8728
5718
0
Q3
Q4
Q1
2013
Q2
Q3
2014
WHO Algorithm 2D
Xpert MTB/Rif Tested
WHO Algorithm 2B
Cumulative Screened
Q4
TBXpert PPM Summary for Case Detection
Up to January 31, 2015
Screening
Start Date
Number of
People
Screened
Suspects
Tests Performed
MTB+ Cases
Detected
Dhaka
Sep 2013
542,670
43,384
33,714
2,327
Jakarta
Nov 2013
42,269
7,419
28,357
4,600
Karachi
July 2013
1,172,724
99,189
33,794
5,969
1,757,663
149,992
95,865
12,896
TBXpert PPM
TBXpert PPM Summary for Treatment
Up to January 31, 2015
Tests
Performed
MTB+ Cases MTB+/Rif+
Detected Cases Detected
%
On treatment
MTB+/Rif-
%
On treatment
MTB+/Rif+
Dhaka
33,714
2,327
130
90%
86%
Jakarta
28,357
4,600
363
47%
15%
Karachi
33,794
5,969
432
86%
90%
Xpert MTB/ Rif+ Case Detection
IRD and Partner Projects
Project Name
Country
Model
TBXpert - Karachi
Pakistan
PPM
TBXpert - Dhaka
Bangladesh
PPM
TBXpert - Jakarta
Indonesia
PPM
TB REACH 3 - Tajikistan
Tajikistan
Public sector
TB REACH 2 - Dhaka
Bangladesh
Private sector
TB REACH 2 - Karachi
Pakistan
Private sector
TB REACH 1 - Karachi
Pakistan
Private sector
NDOH GF Project
South Africa
Public sector
MINE - TB
South Africa
Public sector
Xpert SMS - Malawi
Malawi
Public Sector
Total
No. of Xpert
tests
performed
No. of Rif+ cases No. of Rif+ cases
detected
initiated on Tx
% Rif+ cases put
on Tx
30,236
32,311
27,938
8,643
1,384
2,427
2,163
11473
402
140
345
1383
34
35
18
9
361
110
48
1315
27
33
17
9
90%
79%
14%
95%
80%
94%
95%
100%
4079
3555
124,209
13
23
2,402
11
21
1952
85%
90%
81%
TBXpert MTB/RIF Results Karachi
Q3 2013-Q1 2015 Karachi, Pakistan
TBXpert Testing Site
MTB/RIF Tests
MTB +ve Cases
RIF +ve Cases
Social Business Sites
SZC- Korangi
SZC- Nazimabad
SZC- Malir
Karachi X-Ray - Saddar
Total Social Business
7,065
3,264
915
1,701
12,945
594
179
40
288
1,101
8.4%
5.5%
4.4%
16.9%
8.5%
26
8
0
10
44
4.4%
4.5%
0.0%
3.5%
4.0%
Public Sector/PMDT Sites
Indus Hospital
JPMC
Civil Hospital
SGH-Korangi
SGH- New Karachi
SGH-Liaqatabad
SGH-Qatar
11,502
6,406
2,103
3,188
2,690
1,764
408
2,521
1,451
354
323
773
322
119
21.9%
22.7%
16.8%
10.1%
28.7%
18.3%
29.2%
263
95
21
13
33
7
13
10.4%
6.5%
5.9%
4.0%
4.3%
2.2%
10.9%
Total Public Sector/ PMDT
28,061
5,863
20.9%
445
7.6%
Total all sites
41,006
6,964
17.0%
489
7.0%
2014: Bacteriologically positive notifications in Karachi
N= 9232
5%
8%
14%
20%
51% of all Bact+
identified in
TBXpert-TBREACH
supported sites
8%
6%
4%
3%
CHS-IRD
INDUS HOSPITAL
FG-JPMC KARACHI
21%
11%
SGH
GOOD LIFE BMU
AKHSP
MALC
CDG
OJHA
Other
Bacteriologically Positive Additionality
at Public Sector / PMDT Sites
GeneXpert MTB/Rif Testing in Karachi (Q3 2010- Q4 2014)
New SS+/B+
Pred
1000
TBXpert Starts
900
800
700
600
500
400
Total Additionality = 557
(18% increase in detection from baseline)
300
200
100
0
Q3
Q4
2010
Q1
Q2
Q3
2011
Q4
Q1
Q2
Q3
2012
Q4
Q1
Q2
Q3
2013
Q4
Q1
Q2
Q3
2014
Q4
Quarterly Rif Resistant Case Notification in Karachi
GeneXpert MTB/Rif Testing in Karachi (Q1 2012- Q1 2015)
Baseline
Karachi Rif+Detection
Linear (Baseline)
180
160
TBXpert Project starts screening at
GP clinics and PPM facilities
140
120
100
80
60
40
20
0
Q1
Q2
Q3
2012
Q4
Q1
Q2
Q3
2013
Q4
Q1
Q2
Q3
2014
Q4
Q1
2015
MDR-TB Enrollment and ‘Additionality’ - all Karachi
Karachi MDR
Baseline
Linear (Baseline )
120
TBXpert Starts
100
80
60
40
Total Additionality = 256
(86% increase in detection from baseline)
20
0
Q3
Q4
2010
Q1
Q2
Q3
2011
Q4
Q1
Q2
Q3
2012
Q4
Q1
Q2
Q3
2013
Q4
Q1
Q2
Q3
2014
Q4
Q1
2015
What have we learned
1. Bringing private sector to support public hospitals improves case
notification of drug-susceptible and drug-resistant TB
2. Systematic mass chest X-ray screening for TB cases accessing for-profit
clinics should be free, along with GeneXpert testing and TB treatment
3. Scaling and sustaining standard of care TB diagnosis and treatment
through the for-profit private sector requires fundamentally new
approaches - social business models are a promising approach
Re-thinking Social Business Models for TB Control
Imran Zafar MBA, M.Sc.
CEO, CHS
Affordable prevention, diagnosis and treatment of
infectious and non-communicable diseases
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What is a social business?
Social businesses are sustainable enterprises that use commercial infrastructure and
strategies to target social impact - improving communities and people's lives
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Case Study – Community Health Solutions, Karachi
Set up as a TBXpert social business with three arms:
1. Active Case Finding in the private sector
2. Treatment in the private sector
3. Support for public sector case finding and treatment
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Paid Chest X-rays Performed
Karachi TBXpert Q1 2014- Q1-2015
3500
3000
2500
2000
CXR
1500
1000
500
0
Q1-2014
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Q2- 2014
Q3-2014
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Q4-2014
Q1-2015
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Quarterly Revenues (USD) CHS
12,000
Karachi TBXpert Q1 2014- Q1-2015
10,000
9,570
8,000
6,148
6,000
4,046
4,000
3,354
3,045
2,000
-
Q1
Q2
Q3
2014
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Q4
Q1
2015
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Total MTB+ Cases
2000
Karachi TBXpert Q1 2014- Q1-2015
1800
1600
1400
1200
1411
1000
800
600
818
1027
956
1059
400
200
0
218
224
161
200
Q1
Q2
Q3
Q4
357
Q1
2014
SBM
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2015
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Lessons Learned
1. Constant change to respond to business environment e.g. Moving from
dedicated screeners to physician screening, more experienced field
staff, data rationalization, marketing strategy, targets/incentives.
2. Social business ethos, closer management and energy offers improved
efficiency and innovation, improved targeting of subsidies and greater
public health impact.
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Lessons Learned
3. With initial investments, commercial viability from client fees is
achievable in a low/middle income settings for some services and
target audiences.
4. Price is a barrier to active case finding, although revenues can increase
with higher volumes even with lower prices. Many with the highest
burden are still excluded, therefore, there is a need for free-to-client
diagnostic services for active case finding amongst the poor.
5. By design, the reverse PPM work for improved diagnostics and
treatment in general has no user-based revenues streams, and could be
sustained through performance-based contracting.
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Way Forward
WE KNOW MUCH OF WHAT NEEDS TO BE DONE!
Being more bold and innovative about leveraging private
sector inputs can help us strengthen and expand efforts!
Public Awareness, motivation and marketing
Active Case Finding
Diagnostics
Treatment, Counseling and Support
Data
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What is a social business?
Social enterprises offer new opportunities and capacity that can help scale up TB
control in the private and public sector.
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Acknowledgements
Technical Partners
NTPs of Bangladesh, Indonesia and Pakistan
Social Businesses