Phase 4 - Using the PPA for Strategy and Planning

Phase 4 – Using the PPA for Strategy and Planning

Once the PPA data have been compiled and the visuals are complete, the final step is to work through interpreting the PPA results for priority setting and program planning. The PPA can provide useful insights into how TB services are aligned with patient care seeking patterns and where there might be areas for further system improvement to better serve patients where they seek care. Translation of the results into programmatic action will require broad dissemination of the findings, and stakeholder engagement to interpret the findings and prioritize.

Summarize and Evaluate the PPA Process

Prior to interpreting the results of the PPA, the analysis team should provide a summary of the PPA process and an evaluation of the strengths and weaknesses of the analysis. In the process of summarizing the PPA, it is useful to:

Make a list of the data sources used for each PPA metric
- Explain the strengths and weaknesses of each data source
- Create a table that explains the process of health facility mapping across all the data sources

The quality of data available for the PPA will vary for each country. The PPA team should consider the quality of the data sources used to create the PPA and how that quality may impact their interpretation of the results.
For example:

Is the team comfortable with the type of data sources that were available? What are the weaknesses? What are the strengths?
Based on the available data, where should the team be cautious when interpreting the results? Where does the team feel most comfortable with the results?
- Does the team feel comfortable with using the PPA results at the sub-national level?
If the data sources only provide quality results at the national level, are there areas where better data should be collected to improve the PPA for sub-national use in the future?
Beginning to think about these questions before starting the process of interpreting the results will help ensure that the team appropriately uses the PPA when moving forward in strategy and planning exercises.The PPA should be interpreted alongside other quantitative and qualitative evidence; e.g., epidemiological reviews, TB inventory studies, and routine program surveillance. Having these data and analytical reports available during discussions of the PPA results can strengthen the validity of interpretation.

Interpreting a PPA

The results of the PPA are now ready for interpretation and application to local priority- setting and planning activities. The approach to disseminating and taking action based on the results of the PPA will differ in each country.

However, it is recommended that existing programmatic meetings, supervisory visits, and planning timelines be used to incorporate the PPA into routine programmatic assessments and standard planning cycles.

Translation of the results into programmatic action will require both broad dissemination of the findings as well as stakeholder engagement to identify and prioritize interventions to address gaps along the patient pathway.

It is important to share the results with a wide variety of stakeholders, as each may interpret the results differently based on their role in TB control. To best apply the findings to programmatic action, various expertise from across the health system will be beneficial; i.e. monitoring and evaluation specialists, health systems planners, laboratory network planners, TB care experts, and political decision-makers.

The PPA is based on the idea that TB systems should be patient-centered and as much as possible be aligned with where patients prefer to seek care. Each column of the PPA visual can be reviewed and discussed in turn to unpack the results and inform discussions of relative priorities for action. Some considerations, by column include:

Initial care seeking: Patients tend to initiate care at health facilities in locations and with types of providers that they prefer. The varied distribution of care initiation across different types of health facilities is partly due to the availability of providers as well as to the acceptability and affordability of providers to patients. The distribution of initial care seeking can be compared to the distribution of the source of TB notification to determine if there is significant mismatch. For example, if 50% of care initiation is in the private sector, but only 10% of case notifications come from the private sector, there may be a significant dropout along the care seeking pathway after care initiation in the private sector. Alternatively, a significant proportion of these patients may remain under care in the private sector but are never notified to the NTP.

Diagnostic coverage:The availability of TB diagnostics at different facilities and sectors should be interpreted within the context of the diagnostic pathway planned for the country of interest. For instance, a country may plan for the diagnosis of TB to be based primarily in primary health care clinics (L1) or the plan may call for patients to be referred to the district hospital (L2) for TB diagnosis. Given a particular diagnostic approach, one can determine if there are major gaps in the availability of TB diagnostics at the particular facility level and sector.

Diagnostic access at initial care seeking: Diagnostic access is the product of care initiation and diagnostic coverage. If diagnostic access is low, there might be a mismatch between where patients seek care and where diagnostics are available. Identifying where this happens can help the program provide more diagnostic capacity in highly-accessed facility levels and for preferred provider types.

The diagnostic coverage and diagnostic access indicators provide information on where the greatest gain in case-detection can be made. When applied at the sub-national level, this analysis can identify areas with lower diagnostic coverage or access. Information on diagnostic coverage and access can be combined with information on population size, prevalence or incidence of TB, and current case notification to identify the priority areas of interventions to improve access to TB diagnosis. Additional information on feasibility of patient or specimen referral and capabilities in health facilities can help the program select the best way to improve access to TB diagnosis.

Treatment coverage:Treatment coverage should be interpreted within the context of the treatment pathway planned for the country of interest. For instance, a country may plan for TB treatment to be based primarily in primary health care clinics (L1) or the plan may call for patients to be referred to the district hospital (L2) for TB treatment. Given a particular treatment approach, one can determine if there are major gaps in the availability of TB treatment at different facility levels and sectors. In addition, one can compare diagnostic coverage to treatment coverage to determine if there is a major misalignment between where TB diagnoses are made and where TB treatment is available. The TB program should aim to reduce this misalignment, such that treatment is available as soon as a TB diagnosis is made.

Treatment access: Treatment access is a product of initial care seeking and treatment coverage. If treatment access is low, there may be a mismatch between where patients initially seek care and where TB treatment is available. This provides opportunities to examine whether the availability of TB treatment can be aligned more closely with where patients initially seek care. To do so, it is important to determine whether or not it is necessary to concurrently improve diagnostic access, given that TB treatment follows diagnosis. Expanded diagnostic access is often the first step in improving treatment access.

The following table outlines some useful questions to consider when reviewing the PPA data. Using these questions as guidance, the PPA team should start to formulate a list of important results from the PPA. These results should then be discussed among the PPA team, partners and other stakeholders.

Interpretation Questions

PPA Metrics to Consider	Review of Findings	Understanding Programmatic Interpretations
Place of Initial Care Seeking	Where are my patients initiating their care seeking journey? Is it mostly in the private sector or mostly in the public sector? Do they initiate care mostly in lower level (i.e., level 0 or level 1) health facilities or do they bypass primary care and initiate their care seeking primarily at level 2/3 hospitals? How does care seeking differ by sub-national unit? Are there differences in public and private sector care seeking by sub-national unit? Are there any sub-national units where one level of the health system seems to be more widely used than average?	Looking at the distribution of places for initial care seeking, are there levels of the health system or sectors (e.g. private) that are not relatively well supported by the NTP? Are there interventions that could better engage them? If there is a high proportion of initial care seeking occurring at level 0, what are some possible reasons? Does it relate to the drug/pharmaceutical regulations in the country? Are there ways to engage this level in referral or specimen capture? Does initial care seeking suggest more active screening for TB within patient populations? Which kind of screening strategies could be implemented at each level? Who can be involved to implement the screening strategies? Are there certain levels or sectors that should be targeted with expansion of diagnostic or treatment services; e.g. are there priority regions / areas for private sector engagement or hospital engagement?
Diagnostic Coverage	How well do TB diagnostics align with patient care seeking preferences? If patients prefer to seek care in the private sector, how well covered are private sector facilities with TB services?	If diagnostic services are not well aligned with where patients seek care, how strong are the referral systems between different health facility levels and sectors? Are there areas that should be particularly targeted with improved referral systems, including remote specimen capture, specimen transport, and patient support for patient referral? Are there “best practice” examples where the diagnostic gap is small, e.g. where specimen transport systems exist, that warrant scale-up?
Treatment Coverage	How well do TB treatment services align with patient care seeking preferences? How well does the coverage of TB treatment services align with TB diagnostic services? Does it appear that patients would have to move between facilities for diagnosis and treatment? What is the driver of this movement?	After reviewing the PPA metrics, are there areas that would benefit from greater involvement or engagement of communities in support of TB control (e.g., TB suspect referral or community based treatment monitoring)? Can treatment be decentralized / ensured where patients initiate care; i.e. where they prefer to seek care?
Access to Diagnosis and Treatment at Initial Care Seeking	How does access to TB services compare across sub-national units? Are there some regions that appear to be better aligned than others? What have these regions done well?	Are there some sub-national units that provide examples for other areas?

Applying Results to Planning and Strategy

What follows are three hypothetical examples of how PPA results could be used for planning and strategy exercises, depending on the quality of data included in the analysis and what the results showed about the program.

In one situation, one of the technical partners of the NTP is using the results to work with regional TB control teams.

By conducting the PPA at the sub-national level, the national team is able to work with regional TB control leaders to identify where there are potential alignment issues between care seeking and service availability. Further, the team is using the PPA to provide supporting evidence for the claim that knowledge and engagement with private providers is insufficient given the level of care seeking in this sector. It has identified another program partner who is engaging in mapping of the private sector provider network. Using the PPA, the team can help identify where (geographically) this mapping is most important for TB control. The team will also be using this exercise to make real-time updates to the PPA as new data is collected.

In a second context, a country who implemented the PPA was able to map sub-national results and gain a detailed picture of service availability in both the public and the private sectors.

Because of previous efforts to build a strong TB lab database, the country had robust information on the diagnostic networks in both the public and private sector. Conducting the PPA aligned this data with care seeking information and gave the NTP a picture of where diagnostics might be placed to better meet patients where they are. This country is working on bringing this information to regional lab managers who are responsible for TB labs throughout the country to engage in planning exercises for future diagnostic expansion.

In a third example, an NTP had limited data to complete a PPA. They completed a prevalence survey six years ago, which included one question about where patients sought care for TB-related symptoms. However, the survey was only powered at the national level. The NTP has not yet implemented a national health facility master list, but did conduct a survey of health facilities in a national survey completed four years earlier. In addition, the NTP manages a database of TB microscopy labs for any public sector health facilities and some of the private sector health facilities. Using these data sources, this country has completed a PPA at the national level.

In this final example, the data the country has available did not provide the level of granularity that makes a sub-national pathway useful or reliable.

However, by going through the PPA exercise and developing a national-level pathway, this country can use the PPA to diagnose where new data should be collected which could improve the analysis, and ultimately, strategy and planning work, moving forward. With this in mind, the country will use the PPA framework as a reference as it plans the questionnaire of their new DHS survey, ensuring the survey team asks all the participants who experienced a cough where they sought care. This information will give the survey team the granularity necessary to understand care relevant care seeking patterns at the sub-national level. They will also help advocate to the Ministry of Health to start building a health facility master list which maps the health facilities across the country.