Understanding the complex relationships among actors involved in the implementation of public-private mix (PPM) for TB control in India, using social theory

"I consulted so many doctors": the journey of tuberculosis patients in Bengaluru, India, from first symptoms to diagnosis

BACKGROUND

The circumstances and factors that explain diagnostic and treatment delays in TB are complex. The present study was planned to understand the journey of new pulmonary TB patients from the time they had their first symptom(s) up to the time they started treatment at a government or private health facility in Bengaluru, a metropolitan city in India.

METHODS

In depth interviews were conducted with twenty-six bacteriologically positive TB patients (15 male, 11 females aged 18-56 years) put on first line anti-TB treatment at government and private health facilities in Bengaluru city. Thematic content analysis of the transcript was done using the Framework approach. Constructs of the Health Belief Model were used to create codes in the framework.

RESULTS

Delays were seen in TB diagnosis and treatment in government and private sectors. Pill burden and long duration of treatment were barriers perceived by patients. Myths and lack of knowledge about TB were documented. Patients acknowledged help provided by Non-Government Organizations. All TB patients had received Direct Benefit Transfer support from the national programme.

CONCLUSIONS

Empowering private providers to diagnose TB early and enabling channels for seamless referrals to a facility where anti TB treatment is provided is suggested. Tailored counselling by grass root health workers to deal with pill burden and long duration of treatment may be considered. Dissemination of knowledge about TB at community level by making it a part of agenda during routine interactions may be useful. Supporting wider engagement with non-government organizations in TB diagnosis and follow-up during treatment is recommended.

Approaches, enablers and barriers to govern the private sector in health in low- and middle-income countries: a scoping review

INTRODUCTION

The private sector plays a substantial role in delivering and financing healthcare in low- and middle-income countries (LMICs). Supporting governments to govern the private sector effectively, and so improve outcomes across the health system, requires an understanding of the evidence base on private health sector governance. This paper reports on a scoping review, which synthesised evidence on the approaches used to govern private sector delivery and financing of healthcare in LMICs, the effectiveness of these approaches and the key enablers and barriers to strengthening governance.

METHODS

We undertook a systematic search of databases of published articles and grey literature to identify eligible papers published since 2010, drawing on WHO's governance definition. Data were extracted into a pretested matrix and analysed using narrative synthesis, structured by WHO's six governance behaviours and an additional cross-cutting theme on capacities.

RESULTS

107 studies were selected as relevant, covering 101 LMICs. Qualitative methods and document/literature review were predominant. The findings demonstrate the relevance of the WHO governance behaviours, but the lack of robust evidence for approaches to implementing them. Valuable insights from the literature include the need for a clear vision around governance aims; the importance of ensuring that policy dialogue processes are inclusive and transparent, avoiding interest group capture; the benefits of exploiting synergies between governance mechanisms; and the need to develop capacity to enact governance among both public and private actors.

CONCLUSION

Governance choices shape not just the current health system, but also its future development. Common barriers to effective governance must be addressed in policy design, stakeholder engagement, public and private sector accountability, monitoring and capacity. Achieving this will require in-depth explorations of governance mechanisms and more rigorous documentation of implementation and outcomes in diverse contexts.

Facilitators and Barriers for Private Health Sector Engagement for TB Care in India: A Systematic Review and Meta-Synthesis of Qualitative Research

INTRODUCTION

Private sector engagement is recognized as one of the most critical interventions to achieve the End TB goals in India. We conducted a systematic review and a meta-synthesis of qualitative studies to identify the barriers and facilitators for private sector engagement in TB care in India.

METHODS

A systematic search in electronic databases was done. We assessed the methodological limitations of individual studies, synthesized the evidence using thematic analysis, and assessed our confidence in each finding.

RESULTS

Of the 19 eligible articles included for the qualitative synthesis, 31.5% (6/19) were conducted in northern states of India. Included studies had details from 31 focus group discussions and 303 in-depth interviews conducted among various stakeholders. The synthesis revealed that barriers to engaging the private sector were lack of coordination mechanisms, lack of the National TB Elimination Program (NTEP) staff capacity to deal with the private sector, lack of private practitioners' knowledge on various programmatic aspects, and perceived complexity of the data exchange mechanism. The private sector felt that NTEP was not sensitive to the patient's confidentiality and demanded too much patient data. The private sector considered nonfinancial incentives like recognition, feedback, involving them in planning, and giving them equal status in partnership as powerful enablers for their engagement in TB care.

CONCLUSION

Factors related to the context in which the engagement occurs, the architecture of the engagement, and interaction among the actors contribute to barriers to engaging the private sector for TB care in India. Strengthening policies to protect patient confidentiality, using behavior change communication to NTEP program managers, providing managerial and soft-skill training to NTEP staff, promoting nonfinancial incentives to private providers, establishing a coordination mechanism between the sectors, and simplifying the data exchange mechanisms need to be done to further strengthen the private-sector engagement.

Challenges in engaging the private sector for tuberculosis prevention and care in Nigeria: a mixed methods study

OBJECTIVES

This study aimed to assess the practices of private practitioners regarding tuberculosis (TB), and to ascertain factors related to the low contribution of private healthcare providers to TB prevention and care in Nigeria.

DESIGN

This is a mixed methods study comprising a quantitative retrospective review and qualitative study.

SETTING

Private health facilities (HF) in Oyo State and the Federal Capital Territory (FCT), Nigeria.

PARTICIPANTS

We used routinely collected data on patients with tuberculosis (TB) notified between 1 January 2017 and 31 December 2018. In-depth interviews were also conducted with the clinical staff of the facilities.

PRIMARY AND SECONDARY OUTCOME MEASURES

The study outcomes are practices of TB case notification and treatment outcome, as well as the barriers and enablers of TB notification.

RESULTS

A total of 13 (11.0%) out of 118 private HF were designated as 'engaged' TB care facilities in Oyo State and none (0%) of the 198 private HF in the FCT held this designation. From the 214 patients with presumptive TB, 75 (35%) were diagnosed with TB, 42 (56%) had a bacteriological test done, 12 (16%) had an X-ray of the chest alone and 21 (28%) had other non-specific investigations. Most patients diagnosed were referred to a public HF, while 19 (25%) patients were managed at the private HF. Among them, 2 (10.5%) patients were treated with unconventional regimens, 4 (21%) were cured, 2 (11%) died, 3 (16%) lost to follow-up and 10 (53%) were not evaluated. The general practitioners did not have up-to-date knowledge of TB with a majority not trained on TB. Most referred patients with presumptive and confirmed TB to the public sector without feedback and were unclear regarding diagnostic algorithm and relevant tests to confirm TB.

CONCLUSION

Most private facilities were not engaged to provide TB services although with knowledge and practice gaps. The study has been used to develop plans for strategic engagement of the private sector in Nigeria.

Integrating private health facilities in government-led health systems: a case study of the public-private mix approach in Ethiopia

BACKGROUND

Private health care facilities working in partnership with the public health sector is one option to create sustainable health systems and ensure health and well-being for all in low-income countries. As the second-most populous country in Africa with a rapidly growing economy, demand for health services in Ethiopia is increasing and one-quarter of its health facilities are privately owned. The Private Health Sector Program (PHSP), funded by the United States Agency for International Development, implemented a series of public-private partnership in health projects from 2004 to 2020 to address several public health priorities, including tuberculosis, malaria, HIV/AIDS, and family planning. We assessed PHSP's performance in leadership and governance, access to medicines, health management information systems, human resources, service provision, and finance.

METHODS

The World Health Organization's health systems strengthening framework, which is organized around six health system building blocks, guided the assessment. We conducted 50 key informant interviews and a health facility assessment at 106 private health facilities supported by the PHSP to evaluate its performance.

RESULTS

All six building blocks were addressed by the program and key informants shared that several policy and strategic changes were conducive to supporting the functioning of private health facilities. The provision of free medicines from the public pharmaceutical logistics system, relaxation of strict regulatory policies that restricted service provision through the private sector, training of private providers, and public-private mix guidelines developed for tuberculosis, malaria, and reproductive, maternal, newborn, child, and adolescent health helped increase the use of services at health facilities.

CONCLUSIONS

Some challenges and threats to sustainability remain, including fragile partnerships between public and private bodies, resource constraints, mistrust between the public and private sectors, limited incentives for the private sector, and oversight of the quality of services. To continue with gains in the policy environment, service accessibility, and other aspects of the health system, the government and international communities must work collaboratively to address public-private partnerships in health areas that can be strengthened. Future efforts should emphasize a mechanism to ensure that the private sector is capable, incentivized, and supervised to deliver continuous, high-quality and equitable services.

Key recommendations to strengthen public-private partnership for adolescent health in resource constrained settings: Formative qualitative inquiry in Mongolia, Myanmar and the Philippines

Background

Public health services can be inaccessible for adolescents. The private sector provides many services, but often in parallel to the public sector. This study aimed to understand current private sector engagement in adolescent health service delivery and develop recommendations to strengthen partnerships.

Methods

The study focussed on Mongolia, Myanmar and the Philippines. An initial participatory workshop in each country was followed by semi-structured key-informant interviews (32 in total) with public and private sector actors and adolescents to explore: perceptions of the public and private sectors, strengths and challenges, existing models of partnership, and insights for successful public-private partnership (PPP). Interview transcripts were analysed thematically, with findings and recommendations verified through a second workshop in Mongolia and the Philippines.

Findings

The private sector already plays a significant role in adolescent health care, and stakeholders reported a genuine willingness for partnership. Strengthened PPP was identified as necessary to improve service accessibility and quality for adolescents, unburden the public sector and introduce new technologies, with advantages for the private sector including improved access to training and resources, and an enhanced public image. Recommendations for strengthened PPP included the need to establish the foundations for partnership, clearly define roles and co-ordinate stakeholders, ensure capacity and sustainability, and monitor and evaluate efforts.

Interpretation

This is the first comprehensive study of public-private partnership for adolescent health in the Asia Pacific region. It identifies stakeholders are willing for stronger partnerships and the benefits this partnership will bring. We define eight key recommendations to enable this partnership across sectors.

Understanding the veterinary antibiotics supply chain to address antimicrobial resistance in Lao PDR: Roles and interactions of involved stakeholders

In response to the global call to mitigate risks associated with antimicrobial resistance (AMR), new regulations on the access and use of veterinary antibiotics are currently being developed by the Lao government. This study aims to explore how the implementation of these new regulations might effectively reduce and adapt the sale, distribution and use of veterinary antibiotics in Lao PDR. To this end, we used the theory of change, framing the AMR issue within the context of the stakeholders involved in the veterinary antibiotics supply chain. Qualitative and quantitative methods were used to collect data, based on questionnaires (n=36 antibiotic suppliers, n=96 chicken farmers, n=96 pig farmers), and participatory tools such as a workshop (n=10 participants), semi-structured interviews (n=20), and focus group discussions (n=7 participants). The stakeholders' understanding of the AMR issue and potential challenges related to the implementation of new regulations regarding access and use of antibiotics, were also investigated. We mapped the veterinary antibiotic supply chain in Lao PDR, and analysed the roles and interactions of its stakeholders. Twenty-three stakeholders representing the private and the public sectors were identified. Many informal and formal links connected these stakeholder within this supply chain. The lack of veterinarian-farmer interaction and the evolving nature of the veterinary antibiotics supply chain accentuated the challenges of achieving behaviour change through regulations. Most of the antibiotics found on farms were categorized by the World Health Organisation's as critically important antibiotics used in human medicine. We argue that AMR risk mitigation strategy requires dialogue and engagement between private and public sectors stakeholders, involved in the importation, distribution, sale and use of veterinary antibiotics. This study further highlighted that AMR is a complex adaptive challenge requiring multi-sectoral approach. We believed that a sustainable approach to reduce and adapt veterinary antibiotics use should be prepared in collaboration with stakeholders from private and public sectors identified in this study, in addition to the new regulations. This collaboration should start with the co-construction of a common understanding of AMR issue and of the objectives of new regulations.

Barriers for involvement of private doctors in RNTCP - Qualitative study from Kerala, India

Introduction:

Engaging the private sector effectively has been considered as the single most important intervention required for Revised National TB Control Program (RNTCP) to achieve the overall goal of universal access and early detection. This study attempts to identify the barriers and facilitators in the involvement of private practioners in signed schemes of RNTCP.

Materials and Methods:

Six focus group discussions - four among private sector doctors and two among RNTCP TB key workers and 10 key informant interviews were conducted. Themes were divided into private sector involvement in RNTCP, barriers for private sector involvement, facilitators for private sector involvement and suggestions for better PPP.

Results:

General feel was that private sector involvement in RNTCP was increasing. Public sector at ground level has not really understood the need to engage the private sector. Lack of capacity for public sector staff to understand and deal with private sector, power relations and not taking hospital managements to trust emerged as important barriers for engagement while private sector doctors expressed concerns over patient confidentiality and patient choices, apprehension of losing patients, inability of program to keep commitments and timely payments, poor recognition to private sector, bureaucratic hurdles and cumbersome formalities. Building locally customised partnership schemes, behaviour change for PPP, building managerial capacity of Public sector to deal with private sector, presence of an interphase agency and quality control through a participatory body were important suggestions for improvement of PPP.

Conclusion:

Strategies have to be formulated to customise partnership for private sector doctors using the flexibilities of the program. Strengthening PPP will be possible in presence of strong administrative will and the understanding that personal relationships are the best key to Public Private Partnerships.

A systematic assessment of the concept and practice of public-private mix for tuberculosis care and control

INTRODUCTION

The STOP TB Partnership aims to improve global tuberculosis (TB) control through expanding access to the directly observed treatment short course (DOTS) strategy. One approach to this is 'Engaging all Care Providers', which evolved from 'Public-Private Mix (PPM) DOTS'. The overall aim of this study was to systematically assess whether and to what degree the STOP TB Partnership's four global objectives of engaging all care providers are met through existing PPM interventions. These four objectives are; 1) Increase TB case detection; 2) Improve TB treatment outcomes; 3) Enhance access and equity; 4) Reduce financial burden on patients. The specific objectives of this assessment were to 1) Understand what PPM means to the STOP TB Partnership's PPM Subgroup and to National Tuberculosis Programme managers; 2) Scope the nature of existing country-level PPM interventions and 3) Review PPM practice against the global PPM objectives.

METHODS

We undertook a systematic, multi-facetted assessment. The methods included interviews with National Tuberculosis Programme managers from high burden countries, clarification of key issues with the STOP TB Partnership PPM secretariat and a review of publicly accessible reports and published articles on PPM projects. Both the literature review and interviews with the National Tuberculosis Programme managers yielded data on project characteristics; PPM models at country level; National Tuberculosis Programme partners; and mechanisms for engagement. Matrices were developed from the literature review and the interviews to show the relationship between services and service providers for different PPM projects. Data from the literature were assessed against each of the four global PPM objectives.

RESULTS

Twelve National Tuberculosis Programme managers from high burden countries were interviewed about the scope of PPM partnerships. Understanding of PPM and types of engaged providers varied considerably; 'private-for-profit qualified clinical providers' were the dominant category. The literature review yielded information on 22 projects in which 'private-for-profit qualified clinical providers' were again the dominant category. The contributions made by 'private-for-profit qualified clinical providers' and 'Non Governmental Organisation qualified clinical providers', were assessed against the four global PPM objectives. Reporting on tuberculosis case detection and treatment outcomes was generally good and demonstrated important PPM contributions in these areas. Reporting on equity, access and reduced patient costs was often lacking or inconclusive.

CONCLUSIONS

PPM has improved case detection and treatment outcomes among patients seeking care with private providers. Evidence on reducing patient costs is inconclusive, and there is scope for increasing equity in access to care by systematically engaging those providers who are the primary agents for poor people seeking health care. Guidelines outlining which types of providers best contribute to achieving the four global objectives, along with the resources required by National Tuberculosis Programs for such engagement is needed.