Influencing TB policy and practice in Bangladesh using a Public-Private Mix approach

POLICY BRIEF

Policy messages:

  1. TB case notification can be increased by involving a small number of Private Medical Practitioners (PMPs) in selected areas. This makes scale-up feasible, as training in using the Public-Private Mix (PPM) model does not have to in-clude all PMPs in the area.
  2. The PPM model should be scaled up in other urban areas in Bangladesh.
  3. Adequate human and financial resources should be provided for partnership activities.
  4. The roles and responsibilities of participating agencies and individuals must be defined in a Memorandum of Understanding to develop and sustain effective partnerships.
  5. Systematic implementation of the partnership leads to greater and more effective involvement of PMPs.
  6. PMPs need training to enhance their knowledge on the NTP guidelines.
Research findings:
  1. The involvement of PMPs substantially increased case finding of infectious TB cases.
  2. The PPM model is highly effective in improving access to and quality of TB care in urban settings.
  3. Appropriate protocols, tools and training materials have considerably improved the quality of TB reporting.
  4. The revised protocol for referrals gave PMPs confidence that they would not lose their patients, which greatly increased their motivation to remain in the partnership.
  5. Participatory development of the PPMs and maintenance of close links were crucial in gaining PMP’s willingness to be involved in the PPM.
  6. Joint ownership of decisions and collective responsibility for implementing the partnership contributed to success.
The problem
Bangladesh is among the top 10 high TB burden countries. To reduce this burden, the National TB Control Programme (NTP) in Bangladesh has adopted the Stop TB Strategy, delivered primarily through government-run health facilities. However, major obstacles to implementation remain, primarily due to:
  • insufficient infrastructure;
  • shortage of appropriately trained health personnel;
  • health facility opening times that are inconvenient for working people, which limits access to and acceptability of treatment; and
  • considerable stigma associated with TB.
These obstacles mean that many people showing signs of TB must travel considerable distances to obtain TB care, wait a long time to be seen when they arrive, and may not be dealt with appropriately. These factors also limit patients’ desire and ability to seek early diagnosis and treatment from public services. Consequently, large numbers of people with chest symptoms initially seek care from private health care providers.
Our research
Given this problem, COMDIS-HSD developed a PPM model to involve private doctors in the NTP’s urban TB control activities. We piloted the PPM model in 4 research sites in Dhaka city between 2004 and 2008.
What is the PPM model?
The model asks private doctors to refer patients to designated TB diagnosis Centres for sputum testing. If a patient tests positive for TB, s/he can get a prescription from their private doctor for free TB drugs, also available from the TB diagnosis centres. The model not only allows private doctors to make use of the free testing service and drugs
offered by the NTP, but also allows the TB Centres and private doctors to trace patients and monitor whether treatment was completed.
Pilot results over 4 years:
  • The case notification rate for new SS+ TB cases in the study areas increased steadily and was consistently higher than the national average (see Figure 1)
  • 703 PMPs were trained in technical and operational aspects of TB care, and PPM/TB record-keeping
  • 3,585 sputum smear positive (SS+) TB patients were registered across 5 TB centres;
  • 647 of the 3,585 patients were referred by PMPs
Our methods
We used a systematic, participatory and phased approach to develop the PPM model. We involved stakeholders in developing and revising the:
  • tools and guidelines needed to diagnose patients;
  • national recording and reporting forms;
  • registers to maintain records of the referrals from PMPs; and
  • NTP’s TB treatment algorithm to incorporate a flexible referral mechanism.
Scaling up
After the pilot was found to be effective in 4 research sites in Dhaka City, the NTP started implementing the PPM model in Chittagong, Sylhet, and other areas of Dhaka, covering more than 15 million people. From the inception of the PPM until 2010:
  • 703 participating PMPs referred almost 19,000 TB suspects and 3,959 SS+ TB cases to the designated TB diagnostic centres; and
  • almost 36% of all SS+ TB cases were attributable to involvement of the private sector providers.
This model is now being used to train PMPs to refer clients to NGO, private and government clinics for family planning advice.
This brief is informed by:
Zafar Ullah AN, Huque R, Husain A, et al. Effectiveness of involving the private medical sector in the National TB Control Programme in Bangladesh: evidence from mixed methods. BMJ Open 2012;2: e001534. doi:10.1136/bmjopen-2012-001534
For more information email Dr Rumana Huque at rumanah14@yahoo.com
With thanks to the patients, PMPs and NGOs involved in this study, and the Bangladesh NTP for permission to carry out the study.
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