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To beat TB, we need quality TB care for all people, by all providers

Photographer: Thinh Hung Do // Friends for International TB Relief

Petra Heitkamp

McGill International TB Centre, McGill University, Montreal, Canada

Madhukar Pai

McGill International TB Centre, McGill University, Montreal, Canada

As countries move towards achieving UHC as part of the Sustainable Development Goals, efforts to engage all health providers to close gaps in care have gained more significance. Ensuring universal access to quality TB services is a significant challenge since over a third of the 10 million people estimated to have developed TB in 2018 were not detected or not notified to national TB programs.

This gap is more pronounced in countries with large private sectors, especially those with a high burden of TB. Patient pathways analyses in 13 countries clearly show that over half of all TB patients begin seeking care in the private and informal sectors.

There is plenty of evidence that quality of TB care is suboptimal in the private sector. Standardised patient studies in 4 countries clearly show that quality of TB care in the private health sector is suboptimal. Failure to engage the full range of health care providers for TB leads to serious consequences including, increased transmission due to delayed diagnosis and treatment, excess mortality and morbidity as a result of inappropriate treatment, increased drug resistance as a result of incomplete treatment, catastrophic costs to patients and their families because of out-of-pocket expenditures for private care, and incomplete monitoring and evaluation of TB services. Engaging private and other care providers can also contribute to easing the heavy burden on NTPs and to accelerating the introduction of new technologies.

For these reasons, the WHO policies and global and national TB strategies have long acknowledged the need to engage all providers, including those in the private sector. However, despite public-private mix (PPM) pilots which have shown positive results, a large number of private health providers, who are often the first point of care for patients, remain unengaged in most low- and middle-income countries (LMICs). PPM is still not sufficiently mainstreamed into TB care and control programs. To advocate for greater engagement of private health care providers in efforts to end TB, WHO, the PPM Working Group of the Stop TB Partnership, and global partners released a new Roadmap in October 2018 that identifies clear actions needed to expand the engagement of all care providers towards universal access to care.

There is plenty of evidence that quality of TB care is suboptimal in the private sector.

One of the challenges to implementation of the PPM Roadmap is the fact that there is not enough guidance or sharing of experience on ‘how to’ implement it at the country level. In other words, there is big know-do gap. Also, there are few PPM “champions”, either individuals or organisations, within the TB field, which suffers from insufficient engagement of relevant people and organisations from outside the realm of TB. While there is published literature on PPM (journal articles, WHO guidance), these are soon dated and poorly disseminated, and the wealth of practical insights and data that lies with isolated groups in the field never makes it into peer-reviewed literature. An active, vibrant learning network around TBPPM could address these gaps and build global capacity on private provider engagement (PPE).

To address this need, several stakeholders, led by the PPM Working Group, coordinated by the McGill International TB Centre, and funded by the Bill & Melinda Gates Foundation, launched the TBPPM Learning Network in October 2019. It’s main aim is to activate or invigorate the nascent PPM community of practice by creating, nurturing and leveraging an online resource center on PPM and providing resources to facilitate active engagement between PPM Working Group meetings. Since its launch over 500 people are already engaged in the network, and several webinars have been conducted.

We invite more people to join the network, and help facilitate timely, dynamic, effective and efficient interaction amongst a full range of policymakers, implementers, researchers and others interested in engaging all providers for TB care and prevention. To beat TB, we must engage with all providers, and ensure all patients receive quality care, regardless of where they seek care.

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