Download Private practitioners and public health: weak links in tuberculosis

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Private practitioners and public health: weak links in tuberculosis
control
Mukund Uplekar, Vikram Pathania, Mario Raviglione
Evidence suggests that all sections of the population in poor
countries seek care from private practitioners. The private
medical sector varies considerably between and within
countries in size, composition, level of organisation, types of
services delivered, and socioeconomic groups served. There
are few statistics for the amount of health care delivered by
the private sector in poor countries.1 However, information
on health expenditure suggests that most poor countries
have a large and growing private medical sector. Surveys
indicate that the private sector is an important source of
care, even for poor people and even where public services
are widely available.2 Private practitioners are widely used to
treat people with diseases such as tuberculosis, malaria,
sexually transmitted infections, diarrhoeal disease, and
acute respiratory infections.3 For example, in India 80% of
households prefer to use the private sector for treatment of
minor illnesses and 75% of households prefer to use the
private sector for treatment of major illnesses.4 In nine of the
world’s poorest countries, 47% of visits to private-health
providers were by the poorest 20% of people compared with
59% of visits among the richest 20% .
Communicable diseases dominate the disease burden in
poor countries. Tuberculosis is a leading cause of death of
young people and adults. This disease causes about
8 million new cases and 2 million deaths every year. Despite
much worldwide attention and implementation of the
WHO recommended DOTS strategy by 119 countries, only
40% of estimated tuberculosis cases are notified worldwide.
Experts believe that private practitioners manage a large
proportion of the unreported majority of tuberculosis cases.
The focus of international efforts is on the improvement
of tuberculosis control in the 22 countries with the highest
burden. Panel 1 shows that in nearly all these countries
private expenditure on health accounts for a high
proportion of total health expenditure. Furthermore, most
of this private expenditure is out-of-pocket expense, which
suggests considerable use of private practitioners and
private pharmacies on a fee-for-service basis (panel 1).
Private practitioners
A large proportion of tuberculosis patients in high
prevalence countries such as India, Pakistan, Philippines,
Vietnam, and Uganda first approach a private practitioner.5,6
For example, a household survey in India found that 60%
individuals with a longstanding cough first went to a private
practitioner.7 Another study noted that 88% of rural and
85% of urban patients with tuberculosis first went to a
Lancet 2001; 358: 912–916
TB Strategy and Operations, Stop TB Department, Communicable
Diseases Cluster, World Health Organization, Geneva, Switzerland
(M Uplekar MD; V Pathania MBA, M Raviglione MD)
Correspondence to: Dr Mukund Uplekar
(email: [email protected])
912
private practitioner.8 Other workers have reported a gradual
flow of poor patients from the private sector to mostly free
public clinics.9 However, many of these studies show a delay
in diagnosis ranging from 1 to 6 months, which could lead
to increased disease transmission. Few researchers have
investigated the role of traditional healers in tuberculosis
care, who are often the first point of contact for tuberculosis
patients in poor countries.
Private practitioners treat a substantial proportion of
tuberculosis cases. About 50% of such patients in India are
treated—partly or completely—in the private sector.6 These
cases alone account for a sixth of the world’s burden of this
disease. A similar situation prevails in many high prevalence
countries. Managers of tuberculosis programmes believe
that in many countries only a small proportion of
tuberculosis patients—mainly the well off—seek care from
private practitioners. The basis for this assumption is that
tuberculosis mainly affects the poor who cannot afford
private doctors’ fees and expensive drugs. However, a
recent survey in a Mexican state showed that about a third
of patients who died from tuberculosis were treated in the
private sector. A substantial proportion of all antituberculosis drugs are sold in the private sector in that
country.10 Available information from Korea and Vietnam
Panel 1: Private health expenditure in
22 countries with highest prevalence of
tuberculosis
Country
Private health
expenditure
(% of total)
India
China
Indonesia
Bangladesh
Pakistan
Nigeria
Philippines
South Africa
Ethiopia
Vietnam
Russia
Democractic Republic
of Congo
Brazil
Tanzania
Kenya
Thailand
Myanmar
Afghanistan
Uganda
Peru
Zimbabwe
Cambodia
Out-of-pocket
expenditure
(% of total)
87·0
75·1
63·2
54·0
77·1
71·8
51·5
53·5
63·8
80·0
23·2
63·4
84·6
75·1
47·4
54·0
77·1
71·8
49·5
46·3
63·8
80·0
23·2
63·4
51·3
39·3
35·9
67·0
87·4
59·4
64·9
60·3
56·6
90·6
45·6
38·3
35·9
65·4
87·4
59·4
48·2
50·2
38·2
90·6
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indicate that successful national tuberculosis programmes
do not necessarily attract all tuberculosis patients.5,11
In India researchers reported that 100 private
practitioners working in the slums of Mumbai had
prescribed 80 different drug regimens to their patients with
pulmonary tuberculosis and that most of these regimens
were inappropriate and expensive.12 Tuberculosis
management practices of private practitioners have recently
come under scrutiny worldwide, in places as different as the
Indian subcontinent, South-East Asia, Africa, some
European countries, and USA.3,6,7,8,9,11,12 All these studies
indicate that private practitioners tend to deviate from
recommended tuberculosis management practices. Of
particular concern are those of practitioners in poor
countries with a high burden of tuberculosis. For example,
private practitioners in such countries rely on chest
radiography for diagnosis and rarely refer patients for
sputum microscopy or monitor treatment. Some prescribe
inappropriate drug regimens, often with incorrect
combinations and inaccurate doses for the wrong duration.
Few pay attention to maintenance of records, case
notification is uncommon, treatment defaulters are never
chased, and treatment outcomes are not known.6–9
Threats, opportunities, and new trends
To ignore private practitioners would be an omission on the
part of national tuberculosis programmes, particularly in
places where a substantial proportion of tuberculosis
patients visit private practitioners whose management
practices are suspect. Such doctors seem to pose both
threats to and opportunities for improved tuberculosis
control. If the private medical sector grows into an
alternative unregulated source of care, the goals of national
tuberculosis programmes will be hampered. However,
private practitioners offer major opportunities to improve
tuberculosis control. A private practitioner is a valuable
resource, located close to, and often trusted by, the
community. National tuberculosis programmes could
increase case detection and notification by the inclusion of
private practitioners. Since many patients first approach
these practitioners, there is an opportunity to reduce
diagnostic delay, to reduce subsequent transmission, and to
improve treatment outcomes. There is also the potential to
share service delivery with the private sector and ease the
workload on frontline health workers. Of course, this
possibility has to be traded off against the possible increase
in tasks such as liaison, training, and monitoring and ways
to channel unreasonable out-of-pocket payments into
resource-poor tuberculosis programmes also needs to be
considered.
Finally, tuberculosis control has to be viewed within the
context of health sector reforms, which include
strengthening of the government’s role in providing
information, overseeing of regulation, and financing of
public health interventions in partnership with the private
sector. To sustain tuberculosis control, national
programmes will have to adapt their strategies to these
trends.13,14
A global appraisal
Surprisingly, there is virtually no published evidence on the
value of linking private practitioners to tuberculosis
programmes. To begin addressing this issue WHO did a
global assessment of private practitioners’ participation in
tuberculosis programmes in 23 countries across six WHO
regions, including countries with a high, medium, and low
prevalence of tuberculosis. The assessment focused on
delivery of tuberculosis care by private for-profit
practitioners. Known continuing collaborative initiatives
between local tuberculosis programmes and private
practitioners were appraised. A detailed WHO report along
with country notes is available and can be obtained from the
authors.15 We summarise here the main findings.
Perceptions on collaboration
Panel 2 lists some of the constraints faced in achieving
collaboration between national tuberculosis programmes
and private practitioners. Most apparent among national
tuberculosis programme managers of high burden countries
is lack of will to take on the issue of private practitioners.
First, managers do not consider private practitioners
enough of a problem to divert their attention from their
current activities. Second, they are too preoccupied with the
implementation of demanding public sector DOTS
programmes to venture into what they see as unfamiliar
territory. Third, they believe that eventually patients will
turn away from exploitative and profit-hungry private
practitioners. Fourth, they see little common ground for
collaboration with largely unorganised private practitioners
and, in the absence of operative regulatory mechanisms,
perceive them as unmanageable. Finally, lack of evidence
adds to their inertia. Nonetheless there is general agreement
on the need to act to get private practitioners on board.
Private practitioners generally complain about the
absence of information about tuberculosis programmes.
They doubt that sputum-based diagnosis and a few drugtreatment options supposedly meant for resource-starved
tuberculosis programmes are in the best interest of their
patients. They are critical of the distrust shown towards
them by programme staff. They are reluctant to lose their
patients to the programme and accuse the programme of
discriminating against sputum-negative patients. Private
practitioners admit that they may be unable to take on
certain tasks, such as defaulter retrieval, social support to
patients, and detailed record keeping and analysis.
However, the general view is that collaboration is feasible.
Panel 2: Barriers to public-private collaboration in tuberculosis care
Within the national tuberculosis programme
Within the private medical sector
Ideological opposition
Inadequate training and lack of information
Lack of information on the private sector
Technical doubts about national tuberculosis programme guidelines
Preoccupation with strengthening and expansion
of the national tuberculosis programme
Low priority to public health functions; not remunerative
Prejudices about the profit motive and the behaviour
of private practitioners
Infrastructural limitations to performance of “public health” tasks
such as defaulter retrieval
Weak or absent regulatory mechanisms
Doubts about quality of care within the national tuberculosis
programme
Absence of precedents; little evidence on replicability
Largely unorganised; liaison and interaction challenging
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Panel 3: Approaches to involve private practitioners in tuberculosis programmes
Country (place)
TB prevalence*
Approach Results
DR Congo
(Kinshasa)
High
National TB programme (NTP) provides training to a team
comprising of a doctor, a laboratory technician, and a nurse
each from some Kinshasa city hospitals and polyclinics.
Drugs are provided at subsidised costs. Monitoring by NTP.
Patients managed according
to national guidelines.
Egypt
(Cairo)
Moderate
NTP manager invites leading private chest physicians to join the
NTP; one leading chest physician is also a university Chancellor.
With the help of university teachers, continuing TB education for
in-practice chest physicians is initiated; modifications to TB
education in medical curricula planned. Private laboratories
approached and requested to report results of sputum
examinations of patients referred to them by private
practitioners.
Pilot projects with five
university hospitals starting
DOTS clinics and private
laboratories reporting all
sputum positive cases.
India
(Hyderabad,
Chennai,
Jamnagar,
Delhi)
High
A few running and evolving models: 1) A private non-profit
hospital initiates a DOTS project for patients referred by private
practitioners in the catchment area; treatment supervision
(DOT) done in neighbourhood centres located in private nursing
homes, clinics, and dispensaries. Drugs and supplies from NTP.
2) A voluntary organisation acts as an interface between private
practitioners and NTP to facilitate collaboration. 3) Local
treatment supervisors of NTP assign diagnosed cases to the
patient’s preferred private practitioner agreeable to do
treatment supervision, maintain records, and report defaulters.
4) Local association of doctors trying out graded involvement of
private practitioners ranging from referral to NTP to
implementing a DOTS programme in an area.
1) The project achieves over
90% case detection and cure
rates; potentially replicable.
2) Results awaited.
3) 87 private practitioners
doing DOT for about
200 patients.
4) Private practitioners
enthusiastic about
collaboration; results
awaited.
Kenya
(Nairobi)
High
Kenya’s National Anti-TB Association, an NGO, provides subsidy
on drugs to private hospitals and physicians who in turn follow
NTP guidelines, notify cases, assist in defaulter retrieval and
maintain and submit records. Aim to make a self-sufficient
private DOTS project.
Documentation in process.
Morocco
(Casablanca)
Moderate
Two successive surveys show satisfactory TB management
practices of private physicians. No conscious interventions
undertaken to influence private practitioners. Probable reasons
for good management practices of private doctors: undergraduate
medical curricula provide substantial time (40 hours) for training
in TB and all postgraduates in chest medicine have to work with
NTP before getting a licence to practise.
Private practitioners largely
follow NTP guidelines,
maintain records. Records
made available to NTP too.
Republic
of Korea
Moderate
Two studies undertaken on general practitioners and chest
physicians. Survey results of their own TB management
practices and treatment outcomes of their patients shared with
private doctors.
Improved practices
demonstrated in the
subsequent survey.
United States
(New York City)
Low
Upgrading the clinical services offered by the TB Bureau’s chest
clinics located throughout the city. State-of-the-art and
confidential services including DOT provided free of cost to
referred suspects and patients including HIV counselling and
testing. Extensive educational material produced and
distributed. Establish hotline to address queries instantly.
A four-fold increase in
referrals from private sector.
Decline in resurgent TB
epidemic demonstrated.
Syrian Arab
Republic
Moderate
Dissatisfied by private physicians’ poor response to persistent
and varied approaches to involve them, the NTP manager
convinces the Ministry of Health to execute a decree, banning
sale of anti-TB drugs in private pharmacies.
Effectiveness to be
documented. Illegal Import of
drugs feared.
The Netherlands
Low
Involvement of private practitioners at all levels including
representation on TB Control Policy Committee. Clarity and
consensus on roles and responsibilities of the public sector
staff and private practitioners in managing each patient.
Excellent public-private
collaboration in efforts to
eliminate TB.
The Philippines
(Manila)
High
NTP provides training and drug supplies for DOTS projects
initiated and operated by an upper class private hospital and a
private university hospital in Manila.
Successful projects;
treatment success over 80%.
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Panel 4: Range of intervention to involve private
practitioners
Tools and guidelines for
routine use in private practice
Outlaw TB management
by private practitioners
Involvement in programme planning
Mandatory internships
in TB programmes
Disincentives for
neglect/ignorance
Contracting out programme
implementation
In-practice education
Modify medical
curricula
Recognition and rewards for
positive contribution
Despite the reservations on both sides, public and private
partnerships have apparently worked in some settings.
When WHO’s eastern Mediterranean regional office
asked its member countries to address private practitioner
involvement in tuberculosis control, they obtained three
different approaches (panel 3). The tuberculosis
programme manager of Egypt enlisted the support of
leading chest physicians and university professors.
University hospitals, previously not associated with the
tuberculosis programme, responded by starting DOT
(direct observation of treatment) clinics in teaching
hospitals. As a result, in-practice education of all practising
physicians began and plans were made to upgrade the
undergraduate curriculum. In the Syrian Arab Republic,
frustrated by persistent indifference of private practitioners
despite his staff’s best efforts, the programme manager
convinced the health ministry to ban the sale of
antituberculosis drugs in private pharmacies, which
restricted the role of private practitioners in tuberculosis
care. In Morocco, the manager first studied private
practitioner working practices and found that many were
referring cases to the national programme. The remainder
followed national guidelines and were largely able to achieve
a positive clinical outcome. Most private practitioners also
managed to maintain patient records and made them
available. Careful documentation of national tuberculosis
programmes would be helpful.
Lessons from countries with low prevalence of
tuberculosis
In tackling the resurgence of tuberculosis, the New York
City Tuberculosis Bureau succeeded in eliciting
participation of the private practitioners and laboratories.16
Before a comprehensive intervention programme began in
1992, about 90% of cases were being detected and
managed in the private sector. One of the first steps taken
was to upgrade and improve the clinical services offered by
the Bureau’s chest clinics located throughout the city. The
best treatment including DOT and confidential services
were provided free to patients with suspected and
confirmed disease. The services also included treatment for
latent disease in high-risk individuals, social services, and
HIV testing and counselling. A telephone line was also
established to address queries of private practitioners. As a
result, there was a four-fold rise in referrals from the private
sector to the bureau’s chest clinics. This project has
implications for national tuberculosis programme managers
in poor countries. First, private practitioners should be
encouraged to visit national tuberculosis programmes and
see the services that are provided, which might help to
initiate a partnership. Second, educational material giving
physicians more information about their responsibilities and
THE LANCET • Vol 358 • September 15, 2001
what the national programme can offer specifically to enable
them to follow correct procedures need to be widely and
regularly distributed. A common practice in many national
tuberculosis programmes is turning away patients with
suspected infection referred by private practitioners on the
basis solely of the results of sputum examination. If staff
from the national programme sent a letter thanking the
practitioner for referral and outlined a plan of management,
as practised by the New York City Tuberculosis Bureau,
this action could help to encourage collaboration.
Public-private partnership in tuberculosis control has
deep roots in the Netherlands. Both physicians and
laboratories notify tuberculosis cases to the tuberculosis
clinics. After diagnosis, patients with tuberculosis are almost
always managed jointly but with a clear division of
responsibility. Physicians take care of diagnosis and drug
treatment and public health nurses handle motivation,
education, defaulter retrieval, and management of social
problems. The programme is spearheaded by the Royal
Netherlands Tuberculosis Association and the key elements
of successful partnership are decentralisation, transparency,
mutual respect, working through consensus, private
provider involvement at all levels including the highest level
policy making, continuing dialogue, and quality assurance.
Strategies
Tuberculosis control programmes can follow one of the
three strategies. First, the managers can build a public
delivery system that excludes the private sector through
legislative measures. Second, they could ignore the private
sector and focus on delivery through government-run
services. In effect, there would be two parallel independent
delivery systems. The third option would be to work with
the private sector. Education and information would be one
form of collaboration. More active forms would involve
private practitioners in service delivery. Panel 4 depicts a
spectrum of interventions for national tuberculosis
programmes to try out singly or in combinations.
Local national programme staff and private institutions in
less-developed countries have independently arrived at
similar conclusions; they have sought to include private
practitioners in DOTS programmes, even where the DOTS
programmes are not yet working satisfactorily. The
partnerships meant giving local health-care units greater
autonomy to explore public-private collaborations, which is
in keeping with the trend towards decentralisation within
health systems. In Ahmedabad and Jamnagar in India,
programme paramedics having been given the freedom to
do so, succeeded in making private practitioners hold
treatment boxes (a full course of treatment for a designated
patient), undertake DOT, assist in defaulter tracing, and
maintain essential records without charging fees. These
private practitioners believe that if they work with the
national programme and offer a free service to patients,
these patients and their families may stay with their practice
for treatment of other health problems.
Misuse of drugs by doctors or by practitioners charging
fees for drugs supplied by the programme, and the
involvement of non-qualified providers, may be best
addressed by keeping the collaboration transparent and
widely known. For example, doctors participating in a
collaborative project in Delhi display prominent boards in
their clinics stating that antituberculosis medication is free.
Private doctors in Nairobi make their patients sign an
agreement that clarifies that he or she has chosen private
care knowing that free care is available in the programme
clinics.
Collaboration with private practitioners for tuberculosis
control can pave the way for public-private collaboration for
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control of communicable diseases in general. Private
practitioners are likely to show greater interest in
participating in successful public-private mix projects if care
can be delivered for a range of diseases. Governments may
find broad collaboration attractive, especially if the
transactions costs of dealing with numerous private
providers are spread across several diseases.
Need for research and policy
A conspicuous weakness in national programmes has been
the absence of documentation of experiences and their
dissemination. Programme managers need to be
encouraged and supported to undertake research to help
create an evidence base. The general reluctance to reach out
to private practitioners and include them in public health
programmes stems from negative perceptions rather than
negative evidence. To change this image policymakers will
need to see evidence-based research combined with bold
initiatives. Settings across and within countries vary so
widely that there cannot be one common blueprint that may
be applied by all tuberculosis programmes.
Consultation of private practitioners, tuberculosis
programme managers, policy makers, and researchers
working with private practitioners in high burden countries
was organised in Geneva in August, 2000. The
recommendations of the group could form the basis of an
emerging policy framework. These include: action-oriented
communication with and information gathering on the
private providers; collaboration with the private
practitioners within the DOTS framework; implementation
and evaluation of intervention-research projects and scaling
up of those found to be successful; availability of publicsector support for provision of standardised tuberculosis
care by private providers; and attention to the “public
health” aspects of the control of tuberculosis and other
communicable diseases in the medical curricula.17
There have been increasing calls and global initiatives for
public-private partnerships to improve health of the poor.18
Their thoughtful application to delivery of clinical care at
the grassroots needs attention. Tuberculosis control offers a
suitable platform to make a beginning.
We thank for their input all concerned national TB programme managers
and their staff; relevant WHO staff in country and regional offices; local
health researchers, national planners and policy makers; and importantly,
private general practitioners and chest physicians.
916
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