Academic journal article Bulletin of the World Health Organization

Control of Tuberculosis in an Urban Setting in Nepal: Public-Private Partnership

Academic journal article Bulletin of the World Health Organization

Control of Tuberculosis in an Urban Setting in Nepal: Public-Private Partnership

Article excerpt

Introduction

Tuberculosis (TB) is the most common cause of death in adults, with South Asia being the worst affected region (1, 2). To avoid poor or incomplete treatment, which can lead to relapse, increased transmission, and drug-resistant TB, WHO and the International Union Against Tuberculosis and Lung Disease advocate use of the DOTS strategy (3, 4). A key component of this strategy is direct observation of treatment (DOT): that is, the patient should be "directly observed" as he or she swallows each dose of anti-TB treatment for at least the first two months of treatment by a person responsible to the health services. The DOTS strategy has been implemented successfully in the public sector by many National TB Programmes (NTPs). In South Asia, however, a large number of patients seek treatment for TB from private practitioners (1), particularly in urban centres (5), and the quality of this TB care generally has been shown to be very poor across all five components of DOTS (6-8). Currently, considerable international interest exists in the involvement of private practitioners in the control of TB (9-11), with India, Pakistan, and other countries developing policies for public-private partnerships. Pioneering work has centred on Mahavir Trust Hospital in Hyderabad (12), but this is somewhat context specific, depending as it does on a charitable hospital and a highly experienced chest doctor who has close links with private practitioners.

In Nepal, over 10 000 new cases of smear-positive TB are notified each year (13). In urban areas, 50% of patients with TB are estimated robe managed in the private sector (14) (almost all licenced private practitioners are concentrated in the urban centres); these patients are unregistered. The quality of care for TB patients provided by private practitioners generally is very poor (15), leading to delayed cure, increased numbers of chronic transmitters, and drug resistance, and hence to an increasing incidence of TB. Most patients who use private practitioners are very poor. After the Nepal NTP developed a well-functioning strategy for TB control in the public sector, the programme felt it appropriate to focus on the private sector.

The Nepal NTP and the research team decided to develop a tailor-made public-private partnership for the control of TB in urban Nepal, the principles of which could be applied in other urban settings in the country. Lalitpur municipality, a medium-sized city in the Kathmandu valley with a population of about 200 000, was chosen by the NTP as an appropriate site for this initiative. The project aimed to develop, implement, and evaluate the public-private partnership. The specific research objectives were to assess the feasibility of developing and implementing a public-private partnership and to assess its success using the following criteria: in the study area, the overall cure rate among newly-registered, smear-positive patients with TB consistently attains the international target of 85%; the overall rate of non-completion of treatment is consistently <5%; the overall case notification rare increases after implementation of the public-private partnership; and the overall number of patients with TB treated in the study area with procedures not consistent with the DOTS strategy falls after implementation of the public-private partnership.

Methods

The main providers in the area were considered to be the public sector, a semi-public hospital (largely financed by an international nongovernmental organization but with joint decision-making by the nongovernmental organization and the government), and private providers (i.e., those not working in the public sector) consisting of not-for-profit nongovernmental organizations and for-profit private medical practitioners. Virtually all treatment for TB was thought to be performed by private-for-profit qualified medical practitioners--an assumption subsequently confirmed by a survey of non-allopathic private practitioners and unqualified allopathic medical practitioners in the study area (unpublished data). …

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