Two wrongs can make a right
Public-private partnerships in tuberculosis control

In Asia the majority of tuberculosis (TB) patients get their diagnosis and treatment from private medical practitioners - yet private doctors are notoriously bad at providing adequate TB services. At the same time, public services find it difficult to provide services that are easily accessible to patients. Surprisingly, one approach - public-private partnerships (PPPs) - may address both of these problems.

Research in Nepal has shown that partnerships for TB control are both feasible and effective. The Nepal National Tuberculosis Programme (NTP) approached non-governmental organisations (NGOs) and private practitioners to determine levels of interest in forming partnerships. A working group of representatives from all three groups developed rules for the partnership and encouraged participation from interested parties. The final partners included three private labs and one semi-public lab, a semi-public referral hospital, three NGOs and one private nursing home. Two factors were key to the partnership's development: an equal partnership, in which participants' views were respected; and agreement that there could be no compromise on the fundamental requirements of DOTS (directly observed treatment, short-course).

As a result of the partnership, TB care is much improved. Centres are conveniently sited so patients can visit daily for treatment. Opening times are convenient for patients. The 100 private practitioners in the area can refer patients to the centres, and are informed of patients' progress. The NTP provides free TB drugs to the centres. When the treatment ends, patients are referred back to the original private practitioner. Volunteers from a local NGO visit patients who miss treatment and encourage them to continue to visit the treatment centres. The private nursing home is motivated partly by a desire to provide a service to the community, and partly because of the resultant publicity.

The number of TB patients recorded in the study area has doubled. The treatment success rate is over 90 per cent and less than one per cent of patients has defaulted. Most patients do not have to travel more than 15 minutes to reach the nearest DOTS centre. Many patients bypass private practitioners and go directly to the free centres.

The study's major findings are:

• PPPs are feasible and effective in this context.
• Private practitioners welcome initiatives that help them ensure patients complete treatment and are cured - so long as patients are referred back to them after treatment.
• It is not necessary to involve all private practitioners - only those who are committed.
• The partnership should concentrate on using the strengths of the partners, such as private practitioners' acceptability and convenient opening times, NGOs' community involvement, and the NTP's technical skills and access to drugs.
• PPPs take time and patience to develop, as trust is built.

As the PPPs are shown to be successful, patients start to self-refer, thereby reducing the burden on the partnership. Private pharmacies stop stocking anti-TB drugs, so that uncontrolled access to TB drugs is reduced. Private labs seek accreditation, which enables the NTP to introduce quality control to confirm that the labs carry out their work according to international guidelines. Other groups, such as municipal authorities, ask to be involved.

Implications for policy are:

• Where numbers of private practitioners are high, the NTP should consider setting up PPPs for TB control. Such partnerships can reduce poor treatment by private practitioners and provide an increased level of high quality accessible treatment.
• For long term sustainability, there needs to be equality and respect between partners - the NTP should not dominate, although it clearly has a major role.
• Policy-makers should be aware that badly thought out partnerships might have a negative impact on TB control.
• The success of one PPP can encourage other initiatives.

James Newell
Nuffield Institute for Health
University of Leeds
71-75 Clarendon Road
Leeds LS2 9PL
UK

T +44 (0)113 3436950
F +44 (0)113 3436997
j.n.newell@leeds.ac.uk

See also

• 'The implications for TB control of the growth in numbers of private practitioners in developing countries', in Bulletin of the WHO 2002; 80: 836-837, by J.N. Newell, 2002
• 'A service linkage project between the private and public health sector in Kathmandu Valley, Nepal: A study of the organisation and the delivery of TB treatment and care', in Health Policy and Plannning 17: 78-89, by A.K. Hurtig, S.B. Pande, S.C. Baral et al., 2002

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