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.
- Studies of Sun Quality Health, a PSI-managed franchise network of more than 1,500 clinics in Myanmar, have found that its highly subsidized, quality TB care has achieved greater treatment success than the government-run program. Sun Quality patients, who perceive the franchise as offering relatively affordable and attentive care, are also slightly more likely to be in the lowest-income bracket, suggesting that social franchises owned by informal providers can provide affordable TB care to the poor and increase health equity.
- Smiling Sun Franchise Program was composed of 325 franchisee-owned clinics, more than 8,000 satellite sites, and 6,000 community service providers in Bangladesh. Franchisees delivered services in line with the National Tuberculosis Control Program, including DOTS treatment and microscopy services. Drugs were discounted up to 25%, improving affordability for the poor.
- SkyCare, a franchise network run by World Health Partners (WHP), links 4,000 informal provider-owned social franchises in Bihar, India, which provide TB care and services for visceral leishmaniasis, childhood pneumonia, and diarrhea. Franchisees also sell medications and refer patients to telemedicine centers. According to results reported to CHMI, patients travel half the distance to see a WHP provider when compared to other private providers; and the cost of treatment for their patients with TB is about one-fourth the standard cost of treatment in the formal private sector.
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
- In Bangladesh, a study of informal village doctors trained to refer suspected TB cases for free diagnosis and to provide free DOTS to patients found this approach can be an effective and feasible way to improve access to high quality, affordable TB care in poor rural areas.
- In South Africa, training traditional healers on the management of TB and employing them as DOTS supervisors showed similar treatment completion rates and default rates compared to utilizing nurses and CHWs as treatment supervisors.
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