Tuberculosis

Infectious Air

Tuberculosis (TB) is one of the world’s major causes of illness and death. About two billion people, or one-third of the world’s population, carry the TB bacteria although it can remain dormant for years and most carriers never actually develop active TB disease. An infectious airborne disease, TB has been on the rise since the 1980s, primarily in 22 ‘high burden’ countries in Southeast Asia and Africa. The disease’s resurgence is directly connected to the HIV/AIDS pandemic -- especially in Africa where HIV-related weakening of the normal immune systems has lead to high and spreading transmission rates that directly parallel HIV prevalence. Global access to TB treatment is improving but remains low in many countries and the emergence of both multi- and extreme drug-resistant TB, poses a serious threat to TB treatment and control. On average, an infected individual will infect 10 to 15 others annually.

TB treatment requires six to eight months of daily treatment without breaks. Directly Observed Treatment Short course (DOTS) is the international standard for TB control promoted by WHO in order to assure treatment compliance. In developing countries lack of access to DOTS has contributed to the spread of TB and the development of drug-resistant strains.

Private Sector and TB Control

Private providers are typically the first-line providers of care and medication for TB patients in developing countries. Although developing country studies are few, the evidence suggests that 1/2 of all cases of TB are treated in the private sector, even in countries with 100% access to free treatment in government clinics. Tracking studies in Kenya show that patients move in both directions during te course of treatment - from public to private as a result of frustration with long waiting time or lack of drug stocks, and from private to public as a result of delayed diagnosis, quality concerns, or lack of resources to continue private treatment.

80% of the Global TB Burden in 22 Countries:
  • Afghanistan
  • Bangladesh
  • Brazil
  • Cambodia
  • China
  • Dem. Rep. of Congo
  • Ethiopia
  • India
  • Indonesia
  • Kenya
  • Mozambique
  • Myanmar
  • Nigeria
  • Pakistan
  • Philippines
  • Russian Federation
  • South Africa
  • Thailand
  • Uganda
  • United Rep. of Tanzania
  • Viet Nam
  • Zimbabwe

Unfortunately, private providers in many settings rarely have access to evidence-based practice, training in TB care, or quality medicine. Misdiagnosis, high treatment cost, lack of access to appropriate medications, incomplete regimens prescription, and noncompliance among patients are common problems in TB care. The results are delayed initiation of care and resultant transmission, development of resistant strains, and high mortality rates. All of these highlight the need for strategies to incorporate private providers into national TB programs and DOTS expansion strategies.

Recognizing the necessity of involving all health care providers in TB control, the DOTS Expansion Working Group (DEWG) of the global Stop TB Partnership has formed a subgroup on “public-private mix” for DOTS expansion (PPM-DOTS). Hosted by the WHO, PPM-DOTS develops locally appropriate strategies to link all providers to national TB programs. To date, there have been over 40 PPM-DOTS projects in 15 countries, providing free medications and DOTS training to a broad range of private providers. The results have been promising, including a 10-60% increase in case detection, greater than 85% improvement in treatment outcomes (the target for national TB programs), programs increasingly reaching the poorest populations, and cost savings for national TB program administration.

Strengths

  • Potential early case detection
  • Existing client base
  • Ease of access to care and medications
  • Low overhead
  • Anonymity for clients

Weaknesses

  • Monitoring is difficult
  • Quality of care may vary widely
  • No incentives for official contracts
  • Cost of care may lead to discontinuation
  • Difficult tracking of subsidized medications
  • Perverse incentives towards late diagnosis
  • Lack of laboratory services
  • Little training on extra-pulmonary TB