Vulnerable patients and the public-private mix in tuberculosis
Tuberculosis is a major cause of suffering and death affecting mostly the poor and disadvantaged in resource-poor countries. The majority of sufferers are not currently accessing public TB control programmes and are unlikely to do so in the future without major changes to social conditions and the programmes themselves. There are suggestions that a significant number of persons with active TB do not access any appropriate services. Private providers (PPs) are the main source of treatment for many TB sufferers, but there is evidence that the care they offer is often substandard. Public-Private Mix (PPM) DOTS represents an opportunity for extending the coverage of TB control programmes and improving the case management of TB by PPs by collaboration between public health services and PPs. Looking at the most vulnerable groups by applying what is known or may be inferred about involving PPs in TB care, it would appear that there are likely to be net benefits for some vulnerable groups, such as the urban poor, from PPM DOTS, though each project will need to be evaluated according to the agreements made between the public sector and PPs, the capacity of countries to adequately monitor and regulate PPs and the individual circumstances of the project's area of influence. Some of the problems with PPM DOTS are more concerned with the acceptability to patients of directly observed treatment (DOT) than the private-for-profit aspect and the supervisory and regulatory capacities of the public sectors of resource poor countries will need to be strengthened in order for the implementation of PPM DOTS to be successful.
The size of the gains from PPM DOTS are yet to be seen and may turn out to be small and costly and the difficulties of implementation in resource-poor settings large. This is not a particular criticism of PPM DOTS - it is unlikely that any strategy, or combination of strategies, focusing solely on disease control will succeed in alleviating the burden of TB for the most vulnerable people. For that, multi-sectoral action, and a recognition that most of the countries where TB presents a significant problem will need greater resources in health, environmental and social care than they currently possess, is essential. Overall, therefore, PPM DOTS should be welcomed as an initiative aimed at supporting expansion of DOTS. It should not, however, be seen as the over-arching solution to the current case-detection challenge faced by TB control globally. In addition the needs of vulnerable patients should be considered carefully as more and more PPM DOTS pilots are implemented and evaluated in different settings.
Sykes, M.; Tolhurst, R.; Squire, S.B. Vulnerable patients and the public-private mix in tuberculosis. Liverpool School of Tropical Medicine, (2006) 27 pp.