From Pilots to Systems (Part 1): Achieving systemic and scalable private sector engagement in tuberculosis care and prevention in Asia
Dr. Mukund Uplekar and Madhukar Pai also contributed to this article, which originally appeared on PLOS Medicine.* This is the first of two parts; in Part 2, the authors will discuss how consolidating supplies in tuberculosis care makes everything ?easier?; how economic ?growth ?brings more ?sustainable ?opportunities?; and the evolution of the health workforce.?
As a transmissible, airborne disease, tuberculosis (TB) is a classic public health issue, and the majority of TB prevention and care efforts globally have focused on the public-sector role. However, in sub-Saharan Africa and South Asia, respectively, 49 percent and 81 percent of all patients present initially to private or informal (nonqualified) providers. Many of those patients have TB symptoms and a subset have TB disease, but studies show substantial diagnostic delays and high patient costs that are associated with seeing multiple private providers.
Shortening the pathway for those individuals – from their initial private-sector consultation to quality-assured, evidence-based treatment in either the public or private sector – is no simple task. The initial symptoms of TB are nonspecific, diagnosis requires clinical judgment and laboratory testing, and treatment requires long-term monitoring. Nevertheless, tackling this private-sector issue is essential to lessen the TB burden on both patients and, via reduced transmission, communities.
TB is one of the first health arenas in which this issue of private-provider involvement in long-term care is being tackled seriously in low-income countries. At the global level, WHO’s new End TB Strategy emphasizes the need for such “bold policies and supportive systems.” Here, we outline the current and newer approaches being taken – and the opportunities for more systemic and scalable efforts to engaging private-sector providers in TB control and beyond. Our emphasis is on Asia (based on the large private sector and evidence base), but we expect many conclusions to be broadly applicable.
People do not come to health services labeled as TB patients but rather present with variable and sometimes mild symptoms. For such an individual, a rapid visit to a pharmacy or informal provider, with a (putative) solution dispensed on the spot without a consult fee or prescription, is often far more attractive than a protracted visit and diagnostic process at a public health facility.
In addition to health-seeking evidence from prevalence surveys, multiple studies demonstrate a familiar, three-step pattern: an initial consultation with a pharmacist (often with over-the-counter sales of cough medicines and broad-spectrum antibiotics), followed by one or more visits to private providers, and finally, after much delay, TB diagnosis and treatment in the public sector. In India, TB patients interviewed in the public sector had taken particularly circuitous routes to public-sector TB treatment. All or 86 percent had visited private providers first, and the sequential visits to an average of three formal and informal providers had resulted in substantial delays and costs before the patients eventually made it to the public TB program.
Of course, not all TB patients do get to the public sector for treatment. In 2008-09, enough TB drugs were sold in the private sector in four countries -– India, Pakistan, the Philippines and Indonesia – to treat potentially 65–117 percent of those countries’ TB burdens with a full regimen. It is well documented that such treatment is often of a poor quality, with use of nonrecommended diagnostics, variable TB drug regimens (e.g., 63 different regimens prescribed by 106 providers), and mounting costs and no systems for follow-up (resulting in a doubling of the risk of default).
Quality Requires Knowledge, Behavior Change and Enforcement
For well over a decade, the global TB community has promoted public-private mix (PPM) as the response to this challenge. The PPM approach has been structured in several useful ways. The PPM toolkit developed by the World Health Organization and the Stop TB Partnership’s PPM subgroup enumerates the provider types and organizations to engage. These categories are from both the public sector (including government hospitals, social security organizations, prisons, police and military, and academic institutions) and private sector (including nongovernmental organizations [NGOs] and faith-based organizations, corporate health services, private hospitals, private chest physicians and general practitioners, pharmacies, and traditional healers and other unqualified medical practitioners). The tool for conducting a national situational assessment provides further guidance on determining the progress in engaging these groups and discusses related policy issues.
At its core, PPM is trying to replace low-quality, inefficient and potentially expensive health care provision with rapid, affordable and correct diagnosis and treatment, and monitoring to ensure success.
For program design, the initial efforts in PPM have been based on two major concepts. First, the public sector negotiated contracts with private providers to define who does what. Second, to reach individual providers, organizations stepped in to be the intermediaries between public and private sectors. These intermediary organizations -– to date, typically NGOs – take on the huge task of aggregating and engaging with individual providers, notifying cases to the national TB programs (NTPs) and coordinating with NTPs for free drugs and follow-up.
The quality challenge is related to two issues: insufficient promotion of treatment standards (such as the International Standards for TB Care) and limited regulation of those standards. Corrective actions on these two fronts can reinforce each other. In-service education, collaboration, persuasion and peer support can establish higher standards of health care provision, and regulation can enforce these improved standards to narrow the substantial know-do gap between what providers know and what they do in actual practice. Thus, PPM approaches should not choose between education and regulation, since both are necessary.
The choice of task mixes – who does what – must be clear and be used to maximize efficiencies. Many frontline providers in Asia, and particularly in sub-Saharan Africa, are informal (e.g., traditional healers), resulting in a very low quality of medical care. In these circumstances, the best option is to strictly limit the types of activities permitted by these providers, educate only on these few activities (e.g., symptom screening and referral) and enforce the limitations with regulations. The same applies for pharmacists, who should refer, not treat.
Even if qualified doctors are present in the private sector, some countries with minimal TB treatment in the private sector have opted to ban private sector TB drug sales (see WHO’s 2012 case study, “Restricting the availability of anti-TB medicines in Cambodia”); doctors in these private sectors are expected to refer people with TB to the public sector. Bangladesh presents an interesting middle scenario: Although TB treatment was formerly common in the private sector, the free provision of TB drugs by the public sector was widely publicized, leading to a significant, market-driven decrease in the private-sector sales of TB drugs.
However, in other countries there is such a large private market for TB drugs that a ban is seen as untenable. In this context, regulations focus on two areas. First are efforts to extend laboratory quality assurance systems, previously limited to the public sector, to include private-sector laboratories. Second is to ensure that pharmacies provide TB drugs only with a prescription from a licensed, qualified provider, in some cases for free, and with notification of TB patients by the private sector.
Once the desired change is understood, a key consideration for PPM schemes is their incentive structure. In general, incentives for TB PPM have been based on a combination of factors: motivation and moral persuasion; free extras (training, performance recognition, and free diagnosis and treatment); and, in some cases, limited financial compensation. With any financial mechanism comes major challenges for record verification and then timely and transparent disbursement. Thus, financial incentives make the most sense when patient volumes are large (resulting in administrative economies of scale), such as in laboratories or hospitals with chest physicians, and when the medical or economic stakes are highest, as in the management of multidrug-resistant TB.
Ideally, PPM activities establish a new norm in behavior that persists after the intervention is withdrawn. But results based only on motivation alone may be unstable and, anecdotally, success can be dependent on charismatic local leadership (see FHI Cambodia (2014), “Assessment of public-private mix for TB control in Cambodia”). This may explain the success of pilots but the subsequently variable results in country-wide implementation.
PPM is really a form of behavior change for both sides: for the public sector in their approach to engaging the private sector, and for the private sector in changing their practices. It requires all the usual lessons from this field, such as the use of repetition, learning from the actions of others (social cognitive theory) and peer and group interventions. One potential group for implementing this behavior change is the professional association or society. Members of these associations are well-situated to provide behavior reinforcement messages to their peers. However, most associations have not achieved the organizational scale required for wide coverage of the education function, and they rarely have the manpower for on-site inspections or the mandate to enforce regulations.
The difficultly with regulation is, indeed, enforcement. This mandate would typically fall to government, but professional licensing schemes are often cursory, with no quality component. Does the public sector accept – and have the capacity to address – its responsibility not only to run public facilities but also to regulate and oversee private facilities? India and Indonesia are moving swiftly in this direction (including accreditation for hospitals and laboratories and more formal licensing requirements for providers), and there are signs that others will do so as economies grow. In Cambodia, for example, certain provinces are exploring if the regular renewal of private pharmacy and clinic licenses by the public sector can be used as an opportunity to enforce certain quality and regulation issues.
William Wells is employed by the U.S. Agency for International Development and Dr. Mukund Uplekar is a staff member of the World Health Organization. The views expressed in this article do not necessarily represent the views of these organizations.
* Originally published as “Wells WA, Uplekar M, Pai M (2015) Achieving Systemic and Scalable Private Sector Engagement in Tuberculosis Care and Prevention in Asia. PLoS Med 12(6): e1001842. doi:10.1371/journal.pmed.1001842”