Tuberculosis is the most common cause of death in adults. Many tuberculosis patients in South Asia, the worst affected region of the world, receive very poor treatment from private doctors. A public-private partnership has been set up in Nepal to improve the treatment of the disease.

In urban parts of Nepal 50 percent of tuberculosis (TB) patients see a private doctor. Poor quality of care can lead to relapse, more people becoming infected and drug-resistant strains of the disease developing. As part of their DOTS strategy, The World Health Organisation (WHO) encourages the direct observation of treatment (DOT) to ensure patients complete their course of treatment. DOT means a health worker observes patients swallowing each dose of their medicine.

The UK's Nuffield Institute for Health helped to set up a public-private partnership (PPP) in the Nepalese city of Lalitpur in order to improve the quality of TB care. The city’s district health officer took on the responsibility for running the programme. The aim of the partnership is to combine the strengths of all partners in providing TB care. It involves developing a referral mechanism from private doctors to DOT centres, training health workers, maintaining the drug supply and making sure that the DOT centres follow standard procedures.

Private doctors in the PPP receive maps of the city showing the location of treatment centres and guidelines for referral. Volunteers chase up patients who do not attend the clinics on time for treatment and a chest physician treats complicated TB cases.

The PPP was successful. A survey of TB patients was carried out in 1998 before the PPP was introduced and another survey was conducted three years later. Comparisons of survey results showed that:

• The number of patients diagnosed with TB almost doubled.
• The treatment was successful in more than 90 percent of patients.
• Less than one percent of patients dropped out of the course of treatment.
• The number of TB patients given treatment by private doctors fell by two-thirds.
• Private doctors were happy to refer patients to the public-private partnership.
• Many patients went directly to the free DOTS centres without seeing a private doctor first.

The study suggests that similar arrangements should be made elsewhere in Asia. Setting up a PPP should not be difficult because:

• It requires relatively little additional funding and resources from governments and charities. 
• The process builds on the existing strengths of private doctors, charities and the public sector.

A PPP can provide a service that patients like to use, give high success rates and increase the numbers of patients receiving treatment.  However, a PPP for control of TB should only be set up where the country’s national TB programme is strong. If the national TB programme is weak the private sector with its low cure rates is likely to expand in an uncontrolled way. Such a development could lead to widespread drug-resistant TB and would be disastrous for low-income countries.

Source(s):
‘Control of tuberculosis in an urban setting in Nepal:  public-private partnership’, Bulletin of the World Health Organisation 82(2), by J. Newell et al, 2004 Full document.
Nuffield Centre for International Health and Development: tuberculosis research Full document.

Funded by: UK Department for International Development

id21 Research Highlight: 19 October 2005

Further Information:
James Newell
Nuffield Institute for Health
University of Leeds
Leeds LS2 9PL
UK

Contact the contributor: j.n.newell@leeds.ac.uk

Nuffield Centre for International Health and Development, University of Leeds, UK

Other related links:
'On the same side – public-private partnerships in TB control'

'Two wrongs can make a right – public-private partnerships in tuberculosis control'

'An unlikely couple? Linking private and public sectors in TB control'

'The views of TB control staff on health system decentralisation'

'Tuberculosis control needs strong national health services'

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