Evidence of success: private provider engagement to End TB
Evidence of success: private provider engagement to End TB
Background:
The essential pillar of the TB response is a strong and resilient public health system, including health workforce capacity engaging multiple stakeholders (public, private, community). In our efforts to leave no one behind, we need to detect TB early, ensuring that people affected by TB receive diagnosis, care and support with the provider where they seek care, whether in the public or private sector. Shorter TB pathways in the primary healthcare level with quality TB care are less costly, reduce the risk of spreading TB in the community, and reduce the risk of developing resistance to TB medications.
We now have great evidence that engaging private providers leads to increased TB notifications and good outcomes. We also have WHO dashboard with data of 7 high-TB burden countries highlighting the role of the private sector in End TB targets.
This webinar focused on showcasing real-world examples of what works—highlighting how PPM has made a tangible impact on improving TB outcomes.This webinar showed the data of increased TB notification closing the gap in missing TB people and evidence from concrete projects engaging private healthcare providers, from 35 TB Reach projects, including in Dopasi Foundation in Pakistan as well as in national TB responses as in The Philippines.
Key takeaways
PPM is Essential to Ending TB: Public-private mix (PPM) is not just a strategy; it’s a paradigm shift necessary to reach the millions who miss out on TB care. Engaging all providers, including informal and private ones, is critical to achieving universal health coverage and the End TB goals
PPM is Closing the Notification Gap: In 2023, a significant share of the increase in TB notifications was attributed to PPM efforts. For instance, among the 2.7 million people missing TB care, many were reached through PPM, particularly in priority countries.
TB Reach Projects Show Strong Evidence of Impact: Across 35 TB Reach-funded projects in 19 countries, 58% of the private providers remained engaged, which means that they referred at least one individual with TB. Over the period, they notified or referred around 300,000 presumptive TB individuals for diagnostic evaluation. On average, each private provider referred at least 25 individuals with presumptive TB, ranging between 5 to 171. Of those referred, 85% got tested, and finally, over 54,000 TB patients were diagnosed and notified from these private providers.
Digital Tools Enhance Private Sector Engagement: Countries are increasingly using digital tools (like apps and AI-enabled chest X-rays) for mapping, screening, case tracking, and incentives. These tools are crucial in expanding reach and improving accountability.
Measuring PPM Performance is Key: WHO's enhanced PPM dashboards and the principle of “what’s measured gets done” emphasize the need for routine monitoring and data disaggregation across provider types and levels. These tools help improve advocacy, resource mobilization, and planning.
Country Innovations like Pakistan's Pharmacy Notification Model: Pakistan piloted an app-based notification system for pharmacies, avoiding a ban on private sales of TB drugs while ensuring notification. This model alone led to a 23% increase in notifications in pilot districts and has now scaled to 57 districts nationwide.
Sustaining PPM Requires Policy, Investment, and Trust: The success of PPM depends on embedding it in national strategic plans, securing domestic and donor financing (e.g., Global Fund), and continuing to build trust between public and private sectors. Advocacy efforts are essential to maintain PPM as a priority in TB programming.
Quotes from panelists:
"If you're looking at ending TB, the crux of the problem is that 2.7 million people are still missing out on access to TB care—and this is data from our Global TB Report. Now, the good news is that if you look at the notifications, they've been steadily increasing. Aside from the dip due to COVID between 2020 and 2021, there's been a clear rise. If you look at the increase in 2019 and then again in 2023, a lot of that came from PPM—public-private mix collaboration-led efforts."
"It's the same with drug-resistant TB. We know that around 400,000 people fall ill with it each year, but only one in three actually access care. There's a huge gap in detection and enrollment on treatment. And again, one of the major reasons for this gap is that we're simply not able to reach them. Public-private mix is the answer here as well."
"When you're looking at the TB response with all of its drivers and determinants, you cannot look at it without a multisectoral view. And this is where this comes into play. This is why, in WHO’s Multisectoral Accountability Framework on TB as well, we have this very explicitly mentioned—talking about links with different sectors as well as the private sector."
"You know, there’s a saying: what’s measured gets done. So, if you’re talking about public-private mix, then it’s really critical that you’re measuring it. This is also important for advocacy purposes—to raise resources."
Toufiq Rahman
"In 2023, we have seen that around about 8.2 million of the people who developed TB were notified, out of the estimated 10.8 million people. So we missed around 24% of the individuals who actually developed TB during that period, and engaging private providers is critical to close this notification gap."
"58% of the private providers remained engaged, which means that they referred at least one individual with TB. Over the period, they notified or referred around 300,000 presumptive TB individuals for diagnostic evaluation. On average, each private provider referred at least 25 individuals with presumptive TB, ranging between 5 to 171. Of those referred, 85% got tested, and finally, over 54,000 TB patients were diagnosed and notified from these private providers."
Kinz Ul Eman
"We launched an app called eTB—a platform for notifying people with TB through pharmacies. From an administrative, or rather regulatory, perspective, a notification was issued by the government stating that notification of people getting drugs and the entire treatment from pharmacies is mandatory. This approach combined regulatory measures with a mix of enablers to move this forward."
"We piloted this in four districts of Punjab province in Pakistan, and we saw that in a year's time, we were able to get over 15,000 people affected by TB notified through these pharmacies. This brought the additionality of these districts up by 23%, which means that these people—who were buying drugs from the pharmacies—were actually never being reported to the government through our regular GP model. And because this was all additional notification, it was over and above what we were already historically getting."
"We need to go beyond the conventional actors when it comes to PPM, and pharmacies continue to be a key actor in this space. We need to have a friendly model that includes both a regulatory approach and an enabler approach."
Diana T malari
“According to the 2016 National TB Prevalence Survey, among those with TB screening symptoms, only 19% consulted a healthcare worker, 41% took no action, and 40% self-medicated. Of those who did not consult a healthcare worker, 67% went to public facilities, while 30% went to private providers. This highlights a significant proportion of TB Cases initially seeking care in the private sector.”
“The updated PPM strategic plan was supposedly going to be funded by USAID. However, since the cessation of that support, we were halted in the development. So, we are still looking for possible funders to help us develop the PPM sub-plan.”
Quotes on sustainability
Toufiq Rahman
"Informal private providers are motivated by different incentive mechanisms compared to conventional or formal private providers. For formal private providers, it's not necessarily financial incentives that engage them, because we assume they already have good practices. The incentive for them could be access to new diagnostics, like AI-enabled X-rays, GeneXpert, or other new tools. Additionally, regularly updating them or their staff on new guidelines, like PPM or tuberculosis updates, can also serve as an incentive. Sometimes, we’ve seen that they are eager to contribute to academic publications."
Kinz Ul Eman
"The concept of ownership is important for them to understand—that these providers are your own, not somebody else's. The contribution from the private sector is essentially helping with the country’s case notification and bridging the gaps for us."
Key Readings:
· Public Private Mix Dashboards (WHO)
· The following reading from dopasi