ArticlesEngaging the private sector to increase tuberculosis case detection: an impact evaluation study
Introduction
Although free tuberculosis screening and treatment is available through national tuberculosis programmes (NTPs) in most countries, an estimated 1·45 million people die from tuberculosis every year, making it one of the leading infectious causes of adult deaths globally.1 One important reason for this high death toll is inadequate case finding; more than 3 million of the estimated 8·8 million new cases annually are not notified. Many of these cases are either never diagnosed or receive treatment in the private sector.2 Untreated patients continue to transmit tuberculosis and those treated incorrectly can develop drug resistance; in both cases, mortality is high.3
In Asian megacities, 50–80% of symptomatic tuberculosis patients preferentially seek care in the private sector.4, 5, 6, 7 Patients are often unaware of the free services available, perceive government services to be of poor quality, or are deterred by long waiting times and inconvenient hours.8, 9, 10 At both government and private facilities, many tuberculosis cases are missed because suspects are not identified (ie, symptoms are not screened for or not recognised, or a diagnositic test is not requested).11 Although there has been some success in engaging private health providers in Asian cities, persuading these providers to identify, notify to NTPs, and treat tuberculosis cases has been challenging.12, 13, 14
Harnessing the private sector has long been recognised as a missing component in global efforts against tuberculosis.15 It is unlikely that airborne diseases such as tuberculosis will be eliminated without novel approaches to ensure that patients who present in the private sector have access to appropriate diagnostics and free medication. In settings where strict private-sector regulation is unlikely, incentive-based approaches will be necessary to ensure that high-standard tuberculosis diagnosis and treatment become the norm, rather than the exception.
An optimum case-detection strategy for dense urban settings with mixed public and private care providers would need to engage the private sector, be simple to implement and economically scaleable, and yield high numbers of previously unidentified or unreported tuberculosis cases. We sought to measure the effect of a multifaceted tuberculosis case-detection strategy in Karachi, Pakistan.
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Study design
We retrospectively assessed a multifaceted case-detection strategy that targeted private health-care facilities within a section of Karachi, by comparing the number of cases notified to the NTP in the intervention area with the number of cases notified in an adjacent section of Karachi, over a 1 year period. The adjacent geographical area was identified as a suitable control population by the NTP and an independent monitoring and evaluation agency, through the TB REACH initiative. The control
Results
Between Jan 3, 2011, and Dec 31, 2011, screeners assessed 388 196 individuals at 54 family clinics and identified 6089 people they suspected to have tuberculosis. Screeners also vetted 81 700 people at the Indus Hospital's outpatient department and identified an additional 2405 (figure 1). These 8494 patients yielded 876 with tuberculosis; 603 were from family clinics and 273 from the outpatient department. Indus Hospital's tuberculosis clinic reported 1020 cases from self-referrals and 520
Discussion
By use of incentive-driven mobile-phone-based mass screening by community laypeople at family clinics, and a mass campaign encouraging self-referral to private facilities, we noted that, in 2011 compared with 2010, the number of case notifications doubled in the intervention area and fell slightly in the control area. We also noted a nearly four-times increase in adult pulmonary tuberculosis cases and more than seven-times increase in paediatric cases at Indus Hospital in 2011 compared with
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