Articles
Engaging the private sector to increase tuberculosis case detection: an impact evaluation study

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Summary

Background

In many countries with a high burden of tuberculosis, most patients receive treatment in the private sector. We evaluated a multifaceted case-detection strategy in Karachi, Pakistan, targeting the private sector.

Methods

A year-long communications campaign advised people with 2 weeks or more of productive cough to seek care at one of 54 private family medical clinics or a private hospital that was also a national tuberculosis programme (NTP) reporting centre. Community laypeople participated as screeners, using an interactive algorithm on mobile phones to assess patients and visitors in family-clinic waiting areas and the hospital's outpatient department. Screeners received cash incentives for case detection. Patients with suspected tuberculosis also came directly to the hospital's tuberculosis clinic (self-referrals) or were referred there (referrals). The primary outcome was the change (from 2010 to 2011) in tuberculosis notifications to the NTP in the intervention area compared with that in an adjacent control area.

Findings

Screeners assessed 388 196 individuals at family clinics and 81 700 at Indus Hospital's outpatient department from January–December, 2011. A total of 2416 tuberculosis cases were detected and notified via the NTP reporting centre at Indus Hospital: 603 through family clinics, 273 through the outpatient department, 1020 from self-referrals, and 520 from referrals. In the intervention area overall, tuberculosis case notification to the NTP increased two times (from 1569 to 3140 cases) from 2010 to 2011—a 2·21 times increase (95% CI 1·93–2·53) relative to the change in number of case notifications in the control area. From 2010 to 2011, pulmonary tuberculosis notifications at Indus Hospital increased by 3·77 times for adults and 7·32 times for children.

Interpretation

Novel approaches to tuberculosis case-finding involving the private sector and using laypeople, mobile phone software and incentives, and communication campaigns can substantially increase case notification in dense urban settings.

Funding

TB REACH, Stop TB Partnership.

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.

Section snippets

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

References (28)

  • S Hossain et al.

    Adults with chronic cough in urban Bangladesh: healthcare utilization and management of cases by private practitioners

    World Health Popul

    (2010)
  • Role of private sector in providing tuberculosis care: evidence from a population-based survey in India

    J Glob Infect Dis

    (2011)
  • Y Mahendradhata et al.

    Engaging the private sector for tuberculosis control: much advocacy on a meagre evidence base

    Trop Med Int Health

    (2007)
  • D Lönnroth et al.

    Hard gains through soft contracts: productive engagement of private providers in tuberculosis control

    Bull World Health Organ

    (2006)
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