Reaching the missing 3 million: Exploring the evidence behind efforts to harness informal health providers and fight TB

Of the 9 million people who get sick each year with TB, one-third are “missed” by public health systems. Many are missed because they don’t go to the public health centers participating in TB control efforts. In India, one of the 12 countries accounting for 75% of the missed cases, half of all TB cases are managed in the private sector, a fact highlighted in The Hindu on World TB Day. The private sector is also a major distribution channel for TB drugs: in India, Indonesia, Pakistan, and the Philippines enough TB drugs are sold in their private sectors to treat all TB cases with a full TB drug regimen.

Dr. Madhukar Pai of McGill University states in his Lancet essay on World TB Day that TB care must be delivered with “dignity and compassion, grounded in the reality of patients’ lives as they navigate the long pathway from symptoms to cure.” Care in the private sector can be sub-optimal—with inadequate diagnostic and treatment practices, and lower success rates—but the global community is now acknowledging that all providers and facilities must be harnessed for successful TB control efforts. As a logical next step, many researchers such as Dr. Garima Pathak of the Public Health Foundation of India are now studying how informal health providers, who provide a significant proportion of all health services in many countries, can be effectively incorporated into TB control efforts.

Several CHMI-profiled programs have risen to the challenge and are training informal health providers to offer TB services. Below, we explore their approaches and the evidence to date about what works.      

Partnering with informal health providers to improve access to TB diagnostics and treatment

Programs training informal providers to provide TB care have generally followed one of two formats: 

           1. Training these providers to own and operate their own social franchises, which offer TB services, 
           2. Or, employing informal providers as part of the health program.  

Franchising private clinics offering TB care

CHMI profiles five social franchise programs in which providers own and operate branded branches of health outlets where TB services are standardized, with the goal of increasing access to care, quality, cost-effectiveness, and equity. Several programs coordinate with the National TB Program (NTP) on TB training and quality monitoring, adhere to NTP-approved treatment, provide case detection to NTPs and make appropriate referrals

Employing and training informal providers 

  • Operation ASHA, a nonprofit that establishes TB treatment centers in existing community locales, implements the DOTS program and installs medicine pickup locations in clinics operated by informal providers. Health workers educate patients and ensure that they adhere to their drug regimen. Operation ASHA has 209 treatment centers in 16 Indian cities and 51 centers in Cambodia. The program reports that the TB detection rate in communities where they operate increased by 95% over four years. The death rate for TB patients in South Delhi, in particular, decreased from six to two percent. Operation ASHA has also achieved a cure rate of 91%, exceeding the goals set by India’s Revised National TB Control Program by six percentage points.

Limited but promising evidence for engaging informal providers from Bangladesh and South Africa

Scaling up with targeted guidelines 

Early evidence suggests that informal providers can be a valuable resource to integrate into TB control programs. UCSF’s Private Sector Healthcare Initiative reported that the number of social franchises offering TB diagnostic or treatment services more than tripled globally between 2008 and 2011, with most of these programs operating in Africa, Southeast Asia, and South Asia. Some programs, like Sun Quality Health, operate within the framework of National TB Programs. 

Engaging these frontline providers to work with health programs and networks can very likely improve timely detection and treatment of TB patients, and strengthen health systems. The next step is for the global community to establish practical guidelines to scale up and replicate existing efforts

Photo: The morning drug burden for a patient in an inpatient MDR-TB treatment facility in KwaZulu-Natal, South Africa. © 2012 Amelia Rutter, Courtesy of Photoshare