Private practitioners treat up to half of tuberculosis (TB) patients in urban Nepal, even though free treatment is available in the public sector. Quality of TB care by private practitioners is inconsistent. What is the best way to improve TB control through the private sector?

Despite the increasing number of patients who use the private sector, there are few successful examples of linked public-private TB services. Researchers from the Nuffield Institute for Health and Nepal's National Tuberculosis Centre established a pilot public-private partnership project in Lalitpur municipality.

A working group produced recommendations on:

• provider training
• patient education
• free sputum microscopy
• management of TB patients referred from the private sector to DOTS clinics
• treatment of non-referred patients.

The team disseminated these recommendations to private practitioners through a workshop and individual visits. Later, DOTS was introduced into five clinics in the municipality. Issues that initially needed to be addressed were perceptions that the public sector has the will but not structure or resources to engage with the private sector. The private sector initially lacked interest in public health aspects of TB treatment and trust in the public sector. One year into the programme, an evaluation showed that:

• Non-governmental organisation (NGO) clinics perform well as DOTS centres.
• All five DOTS centres are functioning.
• Most private practitioners do not have the resources to supervise DOTS.
• Private-for-profit practitioners need mechanisms to ensure patients return to them after treatment completion.
• Patients self-refer to DOTS centres.

The public sector has the will but not the structure or resources to engage with the private sector. The private sector lacks interest in public health aspects of TB treatment and trust in the public sector.

The researchers conclude that projects like this require:

• committed leadership
• human resources
• time to develop educational materials and conduct workshops
• use of policies such as DOTS as a catalyst for understanding the needs of TB patients and implementing locally-adapted control strategies
• interaction between the public sector and other organisations
• explicit definition of managerial aspects and responsibilities
• clear guidelines for drug supply and technical support from the national level.

The pilot project showed that any direct linkage between the two sectors in a resource-poor country like Nepal takes time to establish and maintain. A mediator is needed - a role that could be fulfilled by international research institutions or NGOs. Projects of this kind take time to become established, as partners build confidence in each other. However, such partnerships are feasible and sustainable.

Source(s):
'Linking private and public sectors in tuberculosis treatment in Kathmandu Valley, Nepal', Health Policy and Planning 17 (1): 78-89, by A. Hurtig et al., 2002

Funded by: UK Department for International Development

id21 Research Highlight: 4 December 2002

Further Information:
James Newell
Nuffield Institute for Health
71-75 Clarendon Road
Leeds
LS2 9PL
UK

Tel: +44 (0)113 233 6950
Fax: +44 (0)113 233 6997
Contact the contributor: j.n.newell@leeds.ac.uk

Nuffield Institute for Health, University of Leeds, UK

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