Public–private partnership reports success in tuberculosis control in Nepal
6 February 2004
The number of tuberculosis [TB] case notifications in an urban area of Nepal has almost doubled following the establishment of a public-private partnership, according to new research published in this month’s Bulletin of the World Health Organization. After only three years in operation, the programme has also seen treatment success rates exceed international targets. Similar schemes could be applied elsewhere, say the paper’s authors, Newell et al.
“We are currently working to replicate the public-private partnership in other urban centres in Nepal and hope that similar efforts will be possible elsewhere in Asia,” say Newell et al.
The programme, involving private practitioners, nongovernmental organizations and the public sector, was developed by a local working group to deliver the internationally recommended TB control strategy, DOTS, to Lalitpur municipality, Nepal, where it is estimated that 50% of TB patients are treated in the private sector.
After just three years of operation, case notifications increased from 54 per 100 000 to 102 per 100 000 with over 90% of patients successfully treated and less than 1% of patients failing to complete their treatment — figures which significantly exceed international targets. In all, 1,328 TB patients were registered in the public-private partnership, 210 of which were referrals from private practitioners, the remainder having referred themselves.
Direct observation of drug intake, a key element of DOTS, is recommended by WHO and the International Union Against Tuberculosis and Lung Disease to avoid poor or incomplete treatment which can lead to relapse, increased transmission and drug-resistant TB. The DOTS strategy has been successfully implemented in the public sector by many national TB programmes. In South Asia, however, many patients — particularly in poor, urban areas — seek treatment from the private sector, where the DOTS strategy has largely not been adopted.
Tuberculosis is one of the world’s biggest killers – causing nearly two million deaths globally every year, with South Asia being one of the worst affected regions, bearing around a third of the global TB burden.
The authors of the paper, together with Nepal’s National Tuberculosis Programme, developed a tailor-made public-private partnership for TB control in urban Nepal, beginning with Lalitpur — a city of about 200 000 in the Kathmandu valley. The scheme involved diagnosis by private practitioners, direct observation of treatment and tracing of patients who missed appointments by nongovernmental organizations and the provision of training and life-saving drugs by the National TB Programme.
In 1998, prior to the scheme’s implementation, none of the TB patients in the study area were being treated under DOTS. By 2001, however, 16 out of 28 patients diagnosed with TB by private practitioners in the previous month had been referred to the DOTS centres. In the area where the public-private partnership has been implemented, most TB patients do not have to travel more than 15 minutes to reach the nearest DOTS centre.
According to the authors, informal discussions have shown that patients are pleased with the new arrangements. In addition, private practitioners have confirmed that they are confident in the quality and sustainability of the scheme and are happy to refer patients to DOTS centres.
“Nepal is yet another example that demonstrates the benefits of developing field-level partnerships with the private sector to control TB,” said Dr Mukund Uplekar, from the WHO-based secretariat of the Subgroup on Public-Private Mix for DOTS Expansion, an initiative of the global Stop TB Partnership. He also pointed out, however, that such public-private packages should be context-specific.
“While some broad principles of collaboration…can be outlined, what works in Nepal, for example, may not work in Kenya or Pakistan and vice versa. In some projects, for instance, private practitioners have been able to deliver directly observed treatment and ensure patient adherence to treatment,” said Uplekar. The authors also stressed that such a model is appropriate only for countries with strong national TB programmes.
“The public sector must take long-term overall responsibility for public health and needs to show commitment to ensuring that standards of care are maintained and to react quickly when problems arise,” say Newell et al.
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