Engaging for-profit providers in TB control: lessons learnt from initiatives in South Asia: Table 1

Abstract

There has been a huge expansion in the private health-care sector over the past two decades, particularly in South Asia, resulting in over 80% of patients seeking care from private health providers. Despite concerns about the quality and equity of private sector service provision, most government public health bodies recognize that the private sector reaches individuals that public institutions cannot cater to, thereby being important in moving closer to universal health coverage. Numerous initiatives have been launched and are being planned to involve private practitioners in effectively diagnosing, reporting and managing infectious diseases such as tuberculosis. However, there is a notable dearth of papers discussing which elements of private sector engagement strategies are more or less successful and the ethical issues that arise when engagement strategies are operationalized. This article brings together the authors' experiences of working on projects to engage private allopathic health providers in Pakistan, Bangladesh and India for improved tuberculosis control. Motivations of and strategies required to engage private allopathic heath providers, specifically doctors, diagnostic laboratories and pharmacies, and some of the ethical issues that arise when designing programmes for engagement are discussed.

Private Practitioners’ Perspectives on Their Involvement With the Tuberculosis Control Programme in a Southern Indian State

“…Likewise, for those following the AYUSH system of medicine, financial incentives were secondary as compared to the benefit their patients would receive from the TB programme in seeking good health. Similar experiences are shared by Khan et al 86 based on their experience and work with PPM initiatives in South Asia. …”

“…The PPM-TB policy has categorised all types of PPs under one broad group as ‘private providers.’ This single label has not only overlooked the hierarchy amongst practitioners, 86 but has also ignored the different perspectives and potential of each system of medicine and the contribution they can bring to TB control efforts. The PPs are often perceived as ‘money-minded’ or ‘with a business-minded approach,’ and financial incentives are considered one of the best ways to involve them in any health programme.…”

Turning off the tap: stopping tuberculosis transmission through active case-finding and prompt effective treatment

“…Finally, partnerships with the private sector are necessary in settings such as south Asia, where 80% of patients seek care from private providers. 75 In view of the large number and the heterogeneity of private providers, it is an immense undertaking for national tuberculosis programmes to eff ectively engage these providers to ensure that patients with tuberculosis receive timely diagnoses and appropriate treatment, and that all tuberculosis cases are reported to the national tuberculosis programme even if they are diagnosed and treated in the private sector. Although strategies will vary across settings, some approaches that have proven successful include use of large private hospitals with associated clinic networks as reporting centres for the national tuberculosis programme; use of mobile phone-based platforms to help report screening or diagnostic results from private facilities; and mass media campaigns that give publicity to private facilities that have partnered with the national programme to off er testing and treatment.…”

Exploring the evidence base for national and regional policy interventions to combat resistance

“…28 While there is some evidence of the effectiveness of responsible use policies aimed at curbing excess use in publicly funded healthcare systems, evidence from private sector is notably lacking. 29 In areas of the world such as South Asia, where 80% of patients seek care in the private healthcare system, evaluating policies to regulate or modulate antimicrobial use is urgently needed. Case study 1 illustrates the challenges that patients and their physicians routinely face when AMR control policies fail to adequately engage with the private healthcare sector.…”

“…Drugs-for-performance agreements have been successfully applied in several public-private partnerships, as well as incentive based schemes to improve early case detection and encourage the reporting of suspected cases and improve surveillance coverage. 29 These efforts require further support and would be enhanced by legislation making tuberculosis a notifiable disease in Pakistan. The Chennai Declaration, a five-year plan to tackle antibiotic resistance in India 62 may provide a blueprint for other countries in the region including Pakistan to adapt and adopt if demonstrated to be effective.…”