Opinion: Engaging the private sector is vital to ending TB

TB also exposes gaps in the health care system surrounding access, stigma, and inequality, and TB care and prevention are intimately linked to the resilience of the health care system.

The COVID-19 pandemic has highlighted that public health care has been overstretched, leaving private health care providers at the forefront for both pandemic response as well as TB.

Public sector focus

Private providers therefore have a key role, whether it is the pharmacist for medication and referral, or diagnosis and treatment at the village health doctor, private faith-based clinic, or the for-profit hospital. But traditionally, governments manage TB programs with a strong public sector preference.

Countries with large private sectors are showing a changing mindset with more engagement of private providers, with India, Bangladesh, Pakistan, and Nigeria achieving significant scale through using NGOs as intermediaries between government and private primary care providers. In the rebuilding and recovery from COVID-19 and as we prepare for future pandemics and move toward universal health coverage, we need to look to establish a more robust health care system, one that is multisectoral and interdependent.

Pledging a record high of $15.7 billion to tackle HIV, tuberculosis, and malaria, the Global Fund to Fight AIDS, Tuberculosis and Malaria’s seventh replenishment fundraising campaign in September 2022 was a success. Several global leaders have increased their commitments to mobilizing funds and resources — highlighting how the COVID-19 pandemic has pushed governments to consider how we can build more resilient and sustainable systems for health.

Cross-sector collaboration

In our roles as TB experts interested in health system innovation, we believe that engaging the private health care sector in implementing TB care and prevention is more than just involving the corporate business sector in health and disease responses. True public-private collaboration to end TB goes beyond corporate social responsibility and donations and instead calls for engagement of all health care providers in providing TB services across the spectrum of providers.

Both the Global Plan to End TB and the 2023-2028 Global Fund strategy have recognized the need to invest more in engaging the private sector. Doing so would not only improve TB service coverage and quality, data reporting, and increased innovative financing mechanisms but also provide prevention and care within integrated public-private systems.

For example, Kisumu County in western Kenya saw its own form of private sector engagement through the Maliza TB Mashinani project, which provided several private providers including pharmacies, clinics, herbalists, and traditional birth attendants with volunteers trained in TB case finding, allowing them to better navigate the TB network.

Expressing appreciation for the initiative, private providers said they felt more empowered as they were able to identify people with presumptive TB and refer them promptly to the appropriate facilities for diagnosis and treatment. These innovations, among many others, are realities across the world where health solutions have evolved to create a greater role for private providers to play in their countries’ efforts to end TB.

Future potential

There is still unexplored potential for how health programs can integrate and leverage private health care systems. Whereas currently, private providers are contributing 18% to the notification of people with TB, the budget for public-private engagement is only 11% in the current Global Fund TB grants for 11 high-burden countries, according to the Global Fund’s internal analysis.

There is a clear scope for increased investment and increased impact by engaging private providers. With the proper orientation and tools, we can increase case detection, improve treatment outcomes, aid capacity-building, and advance provisions for TB prevention and care.

The TB public-private mix road map outlines strategies and steps to further scale up public-private mix. Private sector engagement requires governance models that allow for more than simply handing over health care to private providers or asking private providers to refer to public health providers. Here are three key recommendations for the way forward, and these considerations depend on the context of each situation:

1. Innovative policy and governance frameworks are needed when engaging private providers, led by strong stewardship in managing markets by national governments, clear regulatory policy and frameworks such as mandatory notification of diagnosed people with TB, contracting guidance in engaging with private providers and facilities and multisector accountability frameworks.

India has many years of experience and has implemented multiple models of private provider engagement, including the Patient Provider Spport Agencies model, which was piloted in three states, expanded through Global Fund grants — implemented by the joint effort to end TB, or JEET — and transitioned to domestic funding. In 2021/2022 this government scheme has expanded the model further across 250 districts throughout the country.

2. Social health insurance schemes showcase how TB services can be funded for people seeking care from a variety of private providers. We need to ensure that disease interventions, including those for TB, are prioritized and integrated in UHC reforms, as the Philippines is currently experiencing.

3. Public-private dialogue is a key stepping stone to any collaborative effort. Through dialogues and communication, we can build relationships and trust, which the World Health Organization defines as key governance behaviors.

Integration of public-private systems is challenging and requires time, patience and willingness to understand different perspectives. For example, Nepal utilized a Global Fund grant to develop a referral mechanism targeting 385 pharmacies. Through communication and incentivizing pharmacies to refer individuals with presumptive TB, pharmacies are empowered with TB knowledge and the ability to serve their clients. Similar pharmacy models have been implemented in Bangladesh, Nigeria, Pakistan, Cambodia, and other countries and are contributing to TB responses.

Scaling up 

Countries with a high TB burden need to take advantage of Global Fund grants, domestic funding, and other sources of funding to scale up successful private sector engagement models as part of their national TB plans, and with that, solidify TB services as a cornerstone of primary health care.

Connecting diverse health financing mechanisms globally is becoming even more important. The engagement of the private sector is essential for comprehensive health systems to reach all people where and when they seek care. Without the engagement of private health care providers and communities, we will not be able to end TB.

By Petra Heitkamp, Dr. Mohammed Yassin

Petra Heitkamp
Petra Heitkamp is a community manager/director at the McGill International TB Centre, managing the TBPPM Learning Network, an online community engaging private health providers in tuberculosis care and prevention. She has 25 years of experience in international health and worked at the Stop TB Partnership and WHO based in India and Indonesia. She was involved in forging partnerships and creating advocacy strategies among stakeholders from global agencies to grassroots tribal leaders.

Dr. Mohammed Yassin
Dr. Mohammed Yassin is a public health physician and infectious diseases epidemiologist with over 25 years of experience. As a senior tuberculosis adviser at the Global Fund since 2010, he provides technical leadership on TB to ensure resources are prioritized for key interventions and vulnerable populations to maximize impact. Dr. Yassin promotes innovation, and partnership and accelerating implementation and monitoring, including via private sector engagement in TB.

Source: Devex