Viewpoint -- Private Practitioners and Public Health: Weak Links in Tuberculosis Control

Communicable diseases dominate the disease burden in poor countries. TB is a leading cause of death in the world for both young people and adults. It results in a million new cases and 2 million deaths each year. Yet, only about 40 percent of TB cases are notified worldwide, despite global attention and implementation of the World Health Organization (WHO)-recommended directly observed therapy (DOTS) in 119 countries.

A large segment of TB patients in countries with a high burden of TB -- like India, Pakistan, Philippines, Vietnam, and Uganda -- first seek out a private provider. A household survey taken in India found that 60 percent of individuals with a longstanding cough went to a private professional. Other surveys indicate a similar set of findings. Yet, many studies also show a delay in diagnosis of TB by private practitioners ranging from one to six months.

About 50 percent of TB patients in India go to the private sector. This accounts for one-sixth of the world's TB cases. And similar usage is reported in other high prevalence countries, and with similar issues of appropriate care. In Mexico, one recent survey showed that about a third of patients who died from TB were treated in the private sector. Private practitioners tend to deviate from recommended TB treatment practices and often rely solely upon chest radiography without follow-up for sputum microscopy. Few maintain records, do report notification or follow up on outcomes.

According to the authors, private sector practitioners offer major opportunities to aid public health programs to improve TB control. National TB programs could increase case detection and notification by the inclusion of private providers, who could share service delivery and ease the workload on frontline providers.

Surprisingly, however, there is no published evidence on the value of linking public health practitioners and private practitioners in efforts to control TB. WHO did a global assessment of private practitioners' activities in TB programs in 23 countries. The study focused upon delivery of TB care by private for-profit providers.

The main findings of the study of countries with high, medium and low prevalence of TB included constraints faced in achieving collaboration between national TB program and private providers. Results indicate that, for national TB programs, the burden of working with private practitioners is the diversion it requires from attention to their current activities. Implementation of the public sector DOTS is thought to consume most of their time and energies. Thirdly, public health personnel believe that eventually the patients will turn away from the for-profit sector. Fourth, national personnel see little collaborative ground for mutual activities, finding private sector practitioners disorganized and essentially unmanageable.

For private practitioners, collaboration with the public sector in TB control offers work in an area for which many feel they are inadequately equipped. They believe that sputum-based diagnosis and the few drug-treatment options available are not in the best interests of their patients, and they are critical of the distrust they feel from program staff. They admit that they may be unable to take on certain tasks, such as social support for their patients and detailed record keeping. Yet, they view the collaboration as nonetheless feasible.

Experience with different collaborative programs offers models for private practitioner involvement in public health efforts at TB control. Lessons from Egypt, the Syrian Arab Republic, Morocco, New York City and the Netherlands offer detailed data on ways in which to set up TB control programs with a spectrum of interventions. Options for future programs offer three strategies. According to the authors, "First the managers can build a public delivery system that excludes the private sector through legislative measures. Second, they could ignore the private sector and focus on delivery through government-run services. In effect, there would be two parallel independent delivery systems. The third option would be to work with the private sector, offering a variety of interventions."

The latter alternative mandates that research be conducted to encourage and support direct collaboration between the public and private sectors. Only evidence-based research combined with bold initiatives can offer solutions for TB programs.

According to the authors, "there have been increasing calls and global initiatives for public-private partnerships to improve the health of the poor. Their thoughtful application to delivery of clinical care at the grassroots needs attention. Tuberculosis control offers a suitable platform to make a beginning."

Back to other CDC news for September 20, 2001

Previous Updates