Alarming rates of attrition among tuberculosis patients in public-private facilities in Lahore, Pakistan

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.

"Together against Tuberculosis": Cascade of Care of Patients Referred by the Private Health Care Providers in the Kyrgyz Republic

Until 2021, in the Kyrgyz Republic, tuberculosis (TB) was diagnosed and treated only in the public sector. With funding support of the STOP-TB partnership, the private providers in four regions of the country and Bishkek city were mapped, trained and incentivized to screen for and identify presumptive TB patients and refer them to the public facilities for diagnosis and treatment. In this study, we describe the cascade of care of such patients. This was a cohort study involving secondary analysis of routine data. Of 79,352 patients screened during February 2021-March 2022, 2511 (3%) had presumptive TB, of whom 903 (36%) were not tested for TB [pre-diagnostic loss to follow-up]. A total of 323 (13%) patients were diagnosed with TB, of whom, 42 (13%) were not started on treatment [pre-treatment loss to follow-up]. Among 257 patients eligible for outcome assessment, 197 (77%) had treatment success, 29 (11%) were lost-to-follow-up, 13 (5%) died, 4 (2%) had treatment failure and 14 (5%) were not evaluated. While this donor-funded, pioneering initiative was successful in engaging the private sector, we recommend that the national TB programme scales up the initiative nationally with dedicated budgets, activities and plans to monitor progress. Qualitative research is urgently needed to understand the reasons for the gaps in the care cascade.

Rethinking Public Private Mix (PPM) Performance in the Tuberculosis Program: How Is Care Seeking Impacting This Model in High TB Burden Countries?

In many high TB burden countries with enormous private-sector presence, up to 60–80% of the initial health-seeking behavior occurs in the private sector when people fall sick. Private-sector providers are also perceived to offer poorer-quality health service, and contribute to TB notification gaps and the spread of multidrug-resistant tuberculosis (MDR-TB). Recent efforts have focused on the expansion of TB services among private providers through public–private mix (PPM) initiatives. However, whether such efforts have matched the contribution of the private sector in TB notification, considering its enormous health-seeking volume, is debatable. Here, we argue that evaluating PPM program performance on the basis of the proportion of private-sector health seeking and level of undernotification is an imperfect approach due to differentials in tuberculosis risk profiles and access among patient populations seeking private care when compared with the public sector. We suggest a uniform definition of what constitutes PPM, and the standardization of PPM reporting tools across countries, including the ability to track patients who might initially seek care in the private sector but are ultimately publicly notified. PPM programs continue to gain prominence with rapid urbanization in major global cities. A universal health coverage framework as part of the PPM expansion mandate would go a long way to reduce the catastrophic cost of seeking TB care.

Predictors of loss to follow-up among adult tuberculosis patients in Southern Ethiopia: a retrospective follow-up study

Background

Loss to follow-up (LTFU) from tuberculosis (TB) treatment and care is a major public health problem as patients can be infectious and also may develop a multi-drug resistant TB (MDR-TB). The study aimed to assess whether LTFU differs by the distance TB patients travelled to receive care from the nearest health facility.

Methods

A total of 402 patient cards of TB patients who received care were reviewed from March 1–30, 2020. The Kaplan-Meir curve with the Log-rank test was used to compare differences in LTFU by the distance travelled to reach to the nearest health facility for TB care. The Cox proportional hazard regression model was used to identify predictors. All statistical tests are declared significant at a p-value< 0.05.

Results

A total of 37 patients were LTFU with the incidence rate of 11.26 per 1000 person-months of observations (PMOs) (95% CI: 8.15–15.53). The incidence rate ratio was 12.19 (95% CI: 5.01–35.73) among the groups compared (those who travelled 10 km or more versus those who travelled less than 10 km). Age ≥ 45 years (aHR = 7.71, 95% CI: 1.72, 34.50), educational status (primary schooling, aHR = 3.54, 95% CI: 1.49, 8.40; secondary schooling, aHR = 2.75, 95% CI: 1.08, 7.03), lack of family support (aHR = 2.80, 95% CI: 1.27, 6.19), nutritional support (aHR = 3.40, 95% CI:1.68, 6.89), ≥ 10 km distance to travel to a health facility (aHR = 6.06, 95% CI: 2.33, 15.81) had significantly predicted LTFU from TB treatment and care.

Conclusions

LTFU from adult TB care and treatment was 12 times higher among those who travelled ≥10 km to reach a health facility compared to those who travelled less. To retain adult TB patients in care and ensure appropriate treatment, health professionals and other stakeholders should give due attention to the factors that drive LTFU. We suggest identifying concerns of older patients at admission and those who travel long distance and establish social support platforms that could help people to complete TB treatment.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-022-13390-8.

Public-Private Mix Models of Tuberculosis Care in Pakistan: A High-Burden Country Perspective

Introduction: Pakistan ranks fifth in the globally estimated burden of tuberculosis (TB) case incidence. Annually, a gap of 241,688 patients with TB exists between estimated TB incidence and actual TB case notification in Pakistan. These undetected/missed TB cases initiate TB care from providers in the private healthcare system who are less motivated to notify patients to the national database that leads to significant underdetection of actual TB cases in the Pakistani community. To engage these private providers in reaching out to missing TB cases, a national implementation trial of the Public–Private Mix (PPM) model was cohesively launched by National TB Control Program (NTP) Pakistan in 2014. The study aims to assess the implementation, contribution, and relative treatment outcomes of cohesively implemented PPM model in comparison to the non-PPM model.

Methods: A retrospective record review of all forms (new and relapse) patients with TB notified from July 2015 to June 2016 was conducted both for PPM- and non-PPM models.

Results: The PPM model was implemented in 92 districts in total through four different approaches and contributed 25% (81,016 TB cases) to the national TB case notification. The PPM and non-PPM case notification showed a strong statistical difference in proportions among compared variables related to gender (p < 0.001), age group (p < 0.000), and province (p < 0.000). Among PPM approaches, general practitioners and non-governmental-organization facilities achieve a treatment success of 94–95%; private hospitals achieve 82% success, whereas Parastatals are unable to follow more than half of their notified TB cases.

Discussion: The PPM model findings in Pakistan are considerably consistent with countries that have prioritized PPM for an increasing trend in the TB case notification to their national TB control programs. Different PPM approaches need to be scaled up in terms of PPM implemented districts, PPM coverage, PPM coverage efficiency, and PPM coverage outcome in the Pakistani healthcare system in the future.

Does time to loss to follow-up differ among adult tuberculosis patients initiated on tuberculosis treatment and care between general hospital and health centers? A retrospective cohort study

BACKGROUND

Patients' loss to follow-up (LTFU) from tuberculosis treatment and care is a growing worry in Ethiopia. But, available information is inadequate in assessing the time to tuberculosis patient loss to follow-up difference between health centers and a general hospital in Ethiopia. We aimed to assess time to LTFU difference between health centers and a general hospital in rural Ethiopia.

METHODS

We conducted a retrospective cohort study from September 2008 to August 2015 and collected data from September 1 to October 02, 2016. A total of 1341 TB patients with known treatment outcomes were included into the study. Log rank test was used to compare the difference in time to TB patient loss to follow-up between health centers and a general hospital, whereas Cox proportional hazard model was used to assess factors associated with time to loss to follow-up in both settings.

RESULTS

We reviewed a total of 1341 patient records, and the overall follow-up time was 3074.7 and 3974 person months of observation (PMOs) for TB patients followed at health centers and a general hospital, respectively. The incidence of loss to follow-up rate was 27.3 per 1000 PMOs and 9.6 per 1000 PMOs, at health centers and a general hospital, respectively. From the overall loss to follow-ups that occurred, 55 (65.5%) and 33 (86.8%) of LTFUs occurred during the intensive phase and grew to 78 (92.9%) and 38 (100%) at health center and a general hospital, respectively, at the end of 6-month observation period. Older age (AOR = 1.7, 95%CI, 1.2-2.5, P < 0.001), being a rural resident (AHR = 2.7, 95%CI, 1.6-4.6), HIV reactive (AHR = 2.2, 95%CI, 1.5-3.2), following treatment and care in health center (AHR = 3.38, 95%CI, 2.06-5.53), and living at more than 10 km away from the health facility (AHR = 3.4, 95%CI, 2.1-5.7) were predictors for time to loss to follow-up among TB patients on treatment and care.

CONCLUSION

Time to TB patient loss to follow-up between health centers and a general hospital was significant. Loss to follow-up was high in patients with older age, rural residence, sero positive for HIV, living further from the health facilities, and following treatment and care at health centers. Strengthening the DOTs program with special emphasis on health centers is highly recommended.

An Innovative Public-Private Mix Model for Improving Tuberculosis Care in Vietnam: How Well are We Doing?

To improve tuberculosis (TB) care among individuals attending a private tertiary care hospital in Vietnam, an innovative private sector engagement model was implemented from June to December 2018. This included: (i) Active facility-based screening of all adults for TB symptoms (and chest x-ray (CXR) for those with symptoms) by trained and incentivized providers, with on-site diagnostic testing or transport of sputum samples, (ii) a mobile application to reduce dropout in the care cascade and (iii) enhanced follow-up care by community health workers. We conducted a cohort study using project and routine surveillance data for evaluation. Among 52,078 attendees, 368 (0.7%) had symptoms suggestive of TB and abnormalities on CXR. Among them, 299 (81%) were tested and 103 (34.4%) were diagnosed with TB. In addition, 195 individuals with normal CXR were indicated for TB testing by attending clinicians, of whom, seven were diagnosed with TB. Of the 110 TB patients diagnosed, 104 (95%) were initiated on treatment and 97 (93%) had a successful treatment outcome. Given the success of this model, the National TB Programme is considering to scale it up nationwide after undertaking a detailed cost-effectiveness analysis.

Does pre-diagnostic loss to follow-up among presumptive TB patients differ by type of health facility? An operational research from Hwange, Zimbabwe in 2017

Introduction

While there are many studies assessing the pre-treatment loss to follow-up (LFU) among tuberculosis patients in public sector, there is no evidence from private-for-profit health sector and pre-diagnostic LFU from Zimbabwe. We aimed to assess the gaps in the cascade of care of presumptive TB patients registered during January-June 2017 in different types of health facilities in Hwange district, Zimbabwe.

Methods

This was a cohort study involving review of routine programme data. Pre-diagnostic LFU was defined as the proportion of presumptive TB patients not tested using sputum microscopy or Xpert MTB/RIF. A log binomial regression was done to assess factors associated with pre-diagnostic LFU.

Results

Of 1279 presumptive TB patients, 955(75%) were tested for TB and 102(8%) were diagnosed as having TB. All TB patients were started on treatment. Pre-diagnostic LFU (overall 25%) was significantly higher among patients visiting private-for-profit health facilities (36%), local self-government run council health facilities (35%) and church-run mission health facilities (25%) compared to government health facilities (14%). Pre-diagnostic LFU was significantly higher among patients in rural areas (30%) compared to urban areas (18%). Type of health facility was associated with pre-diagnostic LFU after adjusting for HIV status and area of residence.

Conclusion

While pre-diagnostic LFU was high, there was no pre-treatment LFU. Pre-diagnostic LFU was especially high in private-for-profit and council health facilities and rural areas. National TB Programme should take immediate steps to improve access in rural areas and support the private-for-profit and council health facilities by improving sputum collection and transport.

Involving private practitioners in the Indian tuberculosis programme: a randomised trial

OBJECTIVES

To assess a multicomponent intervention to improve private practitioners (PPs) involvement in referral of presumptive pulmonary TB (PTB) cases to the Revised National TB Control Programme (RNTCP) for sputum examination.

METHODS

Randomised controlled trial. We randomly allocated all 189 eligible PPs in Tumkur city, South India, to intervention or control arm. The intervention, implemented between December 2014 and January 2016, included two sets of activities, one targeted at health system strengthening (building RNTCP staff capacity to collaborate with PPs, provision of feedback on referrals through SMS) and one targeted at intervention PPs (training in RNTCP, provision of referral pads and education materials and monthly visits to PPs by RNTCP staff). Crude and adjusted referral and PTB case-finding rate ratios were calculated with negative binomial regression.

RESULTS

PPs referred 836 individuals (548 from intervention and 169 from control arm PPs) of whom 176 were diagnosed with bacteriologically confirmed PTB. The proportion (95% confidence interval) of referring PPs [0.59 (0.49, 0.68) vs. 0.42 (0.32, 0.52) in the intervention and control arm, respectively], mean referral rate per PP-year [(5.7 (3.8, 8.7) vs. 1.8 (1.2, 2.8)] and smear-positive PTB case-finding rate per PP-year [(1.5 (0.9, 2.2) vs. 0.6 (0.3, 0.9)] were significantly higher in the intervention than the control arm. Stratifying by qualification, a statistically significant difference in the above indicators remained only among GPs and internists. Overall, surgeons, paediatricians and gynaecologists referred few patients. PP referrals contributed to 20% of the sputum smear positive PTB cases detected by RNTCP in Tumkur city (14% were from intervention arm PPs).

CONCLUSIONS

We demonstrated the effectiveness of a health system-oriented intervention to improve PP's referrals of presumptive PTB cases to RNTCP.