Public-private Mix Research Articles

The feasibility of a public-private mix program on pulmonary tuberculosis screening in Penang: A pilot study.

The low detection rate of tuberculosis (TB) cases in Malaysia remains a challenge in the effort to end TB by 2030. The collaboration between private and public health care facilities is essential in addressing this issue. As of now, no private-public health care collaborative program in pulmonary tuberculosis (PTB) screening exists in Malaysia. To determine the feasibility of a collaborative program between private general practitioners (GPs) and the public primary health clinics in PTB screening and to assess the yield of smear-positive PTB from this program. A prospective cohort study using convenient sampling was conducted involving GPs and public health clinics in the North-East District, Penang, from March 2018 to May 2019. In this study, GPs could direct all suspected PTB patients to perform a sputum acid fast bacilli (AFB) direct smear in any of the dedicated public primary health clinics. The satisfaction level of both the GPs and their patients were assessed using a self-administered client satisfaction questionnaire. IBM SPSS Statistical Software was used to analyze the data. Out of a total of 31 patients who underwent the sputum investigation for PTB, one (3.2%) was diagnosed to have smear-positive PTB. Most of the patients (>90%) and GPs (66.7%) agreed to continue with this program in the future. Furthermore, most of the patients (>90%) were satisfied with the program structure. It is potentially feasible to involve GPs in combating TB. However, a more structured program addressing the identified issues is needed to make the collaborative program a success.

Treatment outcomes of drug susceptible Tuberculosis in private health facilities in Lagos, South-West Nigeria.

BackgroundThe Lagos State Tuberculosis, Buruli Ulcer, and Leprosy Control Program (LSTBLCP) started engaging private hospitals under the Public-Private Mix (PPM) Program in 2008. The study aimed to evaluate the trend and predictors of successful Tuberculosis (TB) treatment outcomes of patients managed across these private health facilities between 2010–2016 in Lagos, Nigeria.MethodsRetrospective review of TB treatment register and treatment cards of patients commenced on TB treatment between January 2010 and December 2016 in 36 private health facilities engaged by the LSTBLCP. Between December 2016 and February 2017, data were collected and entered into Microsoft Excel by trained data entry clerks. The analysis was done using SPSS software. Independent predictors of successful treatment outcomes were determined using multivariate analysis at the statistical significance of p<0.05 and 95% confidence interval.ResultsA total of 1660 records of TB patients were reviewed. 1535 (92.47%) commenced treatment, while 1337 (87.10%) of all records had documented treatment outcomes. Of the 1337 patients with outcomes, 1044 (78.09%) had a successful treatment outcome, and 293 (21.91%) had an unsuccessful outcome. Majority were male, 980 (59.04%), Human Immunodeficiency Virus (HIV) negative status, 1295 (80.24%), diagnosed with smear, 1141 (73.14%), treated in private not-for-profit (PNFP) hospital, 1097 (66.08%), treated for TB between 2014–2016 (18.96%-19.52%). In multivariate analysis, age>20years (aOR = 0.26, p = 0.001), receiving TB treatment in 2013 (aOR = 0.39, p = 0.001), having genexpert for TB diagnosis (aOR = 0.26, p = 0.031) and being HIV positive (aOR = 0.37, p = 0.001) significantly reduced likelihood of successful treatment outcome. The site of TB, being on ART or CPT, were confounding determinants of successful treatment outcomes as they became non-significant at the multivariate analysis level.ConclusionTreatment outcome among Lagos private hospitals was low compared with NTBLCP and World Health Organization (WHO) target. We urge the government and TB stakeholders to strengthen the PPM interventions to improve adherence, particularly among People Living with HIV (PLHIV) and older TB patients. Hence, promotion of early care-seeking, improving diagnostic and case holding efficiencies of health facilities, and TB/HIV collaborative interventions can reduce the risk of an unsuccessful outcome.

Alarming rates of attrition among tuberculosis patients in public-private facilities in Lahore, Pakistan

Aims and objectives: All public-private mix (PPM) facilities caring for tuberculosis (TB) patients in Lahore city, Pakistan, under four models: PPM1 (general practitioners), PPM2 (non-governmental organizations), PPM3 (private hospitals) and PPM4 (others). Methods: This was a retrospective cohort study reviewing existing program records. Poisson regression was used to identify factors associated with outcomes. Data collection, variables and sources: The data were extracted from the TB laboratory registers and TB treatment registers maintained in the PPM facilities. The variables included type of PPM model, laboratory serial number, patient's name, age, sex, date of diagnosis and treatment start, smear grade, type of TB and treatment outcome. The data were collected using a structured proforma. Two electronic databases were created. Results: The two databases were then electronically matched for Results: Of 2473 patients diagnosed, 1590 (64%) were lost to follow-up before treatment. This was higher among males (68%) and the elderly (79%), and lower among 'high positives' (smear grading 2+ or 3+, 53%) and in the PPM1 model (34%). Of 883 patients started on treatment, 165 (19%) had unfavorable outcomes: 8% LTFU, 5% treatment failure, 3% died and 3% not evaluated. Previously treated patients (34%) and children (44%) had the worst outcomes. Conclusion: Pre-treatment LTFU was alarmingly high and requires urgent attention, including the development and institution of mechanisms for patient tracking using information and mobile phone technology, and making TB notification mandatory in the private sector.

Public Private Mix Partnership Model Development Tuberculosis Management Services as an Effort to Accelerate Tuberculosis Elimination in Pasuruan City

Tuberculosis (TB) is still a public health problem in Indonesia and ranks second in the world. Obstacles in implementation of public policies, the National the TB Control Program, the low number of new cases finding, will hinder TB Elimination 2030. The involvement of the private sector and the community in Pasuruan City has increased the case finding rate in the last three years but has not yet reached the target. The finding of TB patients in Diabetes Mellitus (DM) patients is three times higher than the general population, and the prevalence of TB in DM patients is ten times higher than in non-diabetic patients. The purpose of this study was to analyze the partnership model that was carried out and to develop a model for implementing partnerships: Public-Private Mix (PPM) in Pasuruan City. Methodology with a qualitative study goes through the exploration process understands and obstacles of the implementation model the collaboration of the TB control program. Results of the study that principles of partnership that are carried out are only in trust, equality, mutual benefit, and risk-sharing. Then a partnership the model was developed PPM TDC (TB-DM Collaboration), a strategy development to improve case finding and service quality involving primary, secondary and government-private health facilities by collaborating with TB and DM programs, and implementing the principle of Commitment, Cooperation, Trust, Communication, Quality of service, Dependancy, Adaptability, and Profit. As a conclusion of the partnership model: PPM TDC can be an effort to accelerate the achievement of TB elimination. Suggestions for District/Municipality Governments that have implemented PPM are to evaluate and develop the TDC PPM approach, which has not been able to carry directly out the TDC PPM approach. PPM TDC evaluation is carried out by an integrated monitoring team involving academics, professional organizations and periodically.

Assessing the Change of Community Pharmacist’s Knowledge on Tuberculosis and Attitude to practice as a Tuberculosis DOTS provider after an Educational Intervention

Government of India officially launched Directly Observed Treatment-Short course (DOTS) strategy in 1997 to offer better Tuberculosis (TB) care services under Revised National Tuberculosis Control Program (RNTCP). Under this strategy, DOTS providers need to observe and assist the tuberculosis patient to take their DOTS medicine and document the same after each dosing. As part of Public-Private Mix (PPM) partnership under RNTCP, Community Pharmacists (CPs) needs be trained to observe DOTS.This study was aimed to assess the change of CPs basic knowledge on tuberculosis; and attitude to practice as TB-DOTS provider after an educational intervention. Pretest and post test were carried out for 149 participants, to measure the changes in their TB Knowledge and attitude. The changes in the proportions of choices the subjects were analyzed using inferential statistical tests. It was evident from our study that CPs in spite of their knowledge about the TB and the pathogenesis, they were found largely unaware of the Government DOTS-TB treatment national policy and the role they can play in their private practice setups

Importance of Public-Private Mix Collaboration in Tuberculosis Control: It Is Also Valuable in Patients with Multidrug-Resistant Tuberculosis.

Importance of Public-Private Mix Collaboration in Tuberculosis Control: It Is Also Valuable in Patients with Multidrug-Resistant Tuberculosis.

PIN84 Insights into the Contribution of Public-Private Mix Intervention to Tuberculosis Case Notification in Pakistan: A Lower-Middle-Income Country Perspective

PIN84 Insights into the Contribution of Public-Private Mix Intervention to Tuberculosis Case Notification in Pakistan: A Lower-Middle-Income Country Perspective

Treatment Outcomes of Patients with Multidrug-Resistant Tuberculosis: Comparison of Pre- and Post-Public-Private Mix Periods.

BackgroundThis study compared the treatment outcomes of patients with multidrug-resistant tuberculosis (MDR-TB) before and after the implementation of public–private mix (PPM). Factors affecting treatment success were also investigated.MethodsData from culture-confirmed pulmonary MDR-TB patients who commenced MDR-TB treatment at Pusan National University Hospital between January 2003 and December 2017 were retrospectively reviewed. Patients were divided into two groups in terms of PPM status: pre-PPM period, patients who commenced MDR-TB treatment between 2003 and 2010; and post-PPM period, patients treated between 2011 and 2017.ResultsA total of 176 patients were included (64 and 112 in the pre- and post-PPM periods, respectively). 36.9% of the patients were resistant to a fluoroquinolone or a second-line injectable drug, or both. The overall treatment success rate was 72.7%. The success rate of post-PPM patients was higher than that of pre-PPM patients (79.5% vs. 60.9%, p=0.008). Also, loss to follow-up was lower in the post-PPM period (5.4% vs. 15.6%, p=0.023). In multivariate regression analysis, age ≥65 years, body mass index ≤18.5 kg/m2, previous TB treatment, bilateral lung involvement, and extensively drug-resistant (XDR)- or pre-XDR-TB were associated with poorer treatment outcomes. However, the use of bedaquiline or delamanid for ≥1 month increased the treatment success.ConclusionThe treatment success rate in MDR-TB patients was higher in the post-PPM period than in the pre-PPM period, particularly because of the low rate of loss to follow-up. To ensure comprehensive patient-centered PPM in South Korea, investment and other support must be adequate.

The role of faith-based health professions schools in Cameroon’s health system

ABSTRACT Faith-based health professions schools contribute to the training of staff in many Sub-Saharan African countries. Yet little is known about these actors, their role in the health system, potential comparative advantages and challenges faced. This is a qualitative study drawing on 24 qualitative interviews and 3 focus group discussions. Participants included faith-based health professions schools, staff at faith-based health professions schools, Ministry of Health officials and donors. Thematic analysis was used to analyse the data. The findings reveal that understanding of faith-based health professions schools held by donors and the Ministry of Health rest on a set of assumptions rather than evidence-backed knowledge and that knowledge on key aspects is missing (not least on the market share of such actors). This suggests that collaboration with and oversight of these non-state schools is limited, raising questions about the balance of state regulation and control in the public-private mix for training health workers. Linked to this weak oversight, the findings also raise concerns over a number of problematic activities at these schools, unaccredited training programmes and the presence of missionary volunteers whose presence and actions are rarely interrogated.

The falling growth in the use of private hospitals in Australia

Australia has a rich public-private mix of financing and provision of healthcare. Since mid-2015, the higher growth in out of pocket costs relative to the growth in wages began to reduce the affordability of private healthcare and marked the start of the drop in private health insurance coverage. Using publicly available data, this paper describes the decline in growth in the utilisation of private hospital care before and after 2015. Growth in the use of elective surgery in private hospitals fell with some indication of increased waiting times in public hospitals, and evidence of doctors spending more of their time in public hospitals rather than in private practice. Private hospitals’ profitability declined, share prices of for-profit private hospital operators fell, and there is evidence of reduced capacity and a fall in long-term investment in the private hospital sector. In 2020, COVID-19 has accelerated these trends and the economic recession is likely to exacerbate reduced affordability of private healthcare. Policy responses should depend on how these changes influence access, cost and quality of care for patients.

Reasons why patients with tuberculosis in South Korea stop anti-TB treatment: a cross-sectional study.

BACKGROUND: As there had been no reduction in the TB burden in South Korea since 2000, a public-private mix (PPM) strategy was launched in 2011. The purpose of this study was to investigate the reasons for lost to follow-up (LTFU) among TB patients and their clinical characteristics.METHOD: A multicentre, cross-sectional study based on in-depth interviews with patients and their families by TB specialist nurses was conducted. Patients who were reported with a final outcome of LTFU in 2015-2017 at all PPM hospitals across the country were enrolled. Enrolled patients were classified into six subgroups by age and three major reasons for LTFU (adverse effects, refusal of treatment, marginalisation) and their clinical features were compared.RESULTS: Among 780 patients, those who were lost to follow-up due to adverse effects accounted for the largest proportion (n = 387). LTFU in those aged <65 years who refused treatment (n = 189) and those aged <65 years who were marginalised (n = 108) were related to having smear-positive TB and a previous history of unfavourable outcomes.CONCLUSION: To reduce LTFU in South Korea, comprehensive strategies, including management of adverse effects, systematic counselling and education, should be implemented.

Prediction of treatment failure and compliance in patients with tuberculosis

BackgroundTo improve treatment outcomes for tuberculosis (TB), efforts to reduce treatment failure are necessary. The aim of our study was to describe the characteristics of subjects who had failed treatment of tuberculosis and identify the risk factors for treatment failure and poor compliance using national data.MethodsA multicenter cross-sectional study was performed on tuberculosis subjects whose final outcome was reported as treatment failure during 2015–2017. The same number of subjects with treatment success during the same study period were randomly selected for comparison. Demographics, microbiological, radiographic, and clinical data were collected based on in-depth interviews by TB nurse specialists at all Public Private Mix (PPM) participating hospitals in South Korea.ResultsA total of 52 tuberculosis patients with treatment failure were enrolled. In a multivariable analysis, the presence of diabetes, previous history of tuberculosis, and cavity were identified as risk factors for treatment failure; and Medicaid support was a favorable factor for treatment success (area under the curve [AUC]: 0.79). Age, low body mass index (BMI), presence of diabetes, preexisting lung disease, positive sputum acid-fast bacilli (AFB) smear result, and the presence of multidrug-resistant tuberculosis (MDR-TB) were significantly associated with presence of cavities. Younger age, lower BMI and previous history of TB were associated with poor compliance during treatment (AUC: 0.76).ConclusionTo reduce treatment failure, careful evaluation of the presence of diabetes, previous TB history, underlying lung disease, cavity, results of sputum AFB smears, and socioeconomic status are needed. To enhance treatment compliance, more attention should be paid to younger patients with lower BMIs during follow-up.

Profile of general hospitals in the Unified Health System.

ABSTRACTOBJECTIVE To characterize the organization of Brazilian general hospitals that provide services to the Unified Health System using indicators that describe the main dimensions of hospital care.METHODS A 2015 cross-sectional observational study, comprising the range of general hospitals that serve the Unified Health System. We constructed the hospital indicators from two national administrative databases: the National Registry of Health Facilities and the Hospital Information System of the Unified Health System. The indicators include the main dimensions associated with hospital care: public-private mix, production, production factors, performance, quality, case-mix and geographic coverage. Latent class analysis of indicators with bootstrapping was used to identify hospital profiles.RESULTS We identified three profiles, with hospital size being the variable with the highest degree of belonging. Small hospitals show low occupancy rates (21.36%) and high participation of hospitalizations that could have been solved with outpatient care, besides attending only medium complexity cases. They receive few non-residents, indicating that they are mainly dedicated to the local population. Medium-sized hospitals are more similar to small-sized ones: about 100% of the visits are of medium complexity, low occupancy rate (45.81%), high rate of hospitalizations for primary care sensitive conditions (17.10%) and relative importance in the healthcare provision of non-residents (26%). Large hospitals provide high complexity care, have an average occupancy rate of 64.73% and show greater geographical coverage.CONCLUSIONS The indicators point to three hospital profiles, characterized mainly by the production scale. Small hospitals show low performance, suggesting the need to reorganize hospital care provision, especially at the municipal level. The set of proposed indicators includes the main dimensions of hospital care, providing a tool that can help to plan and continuously monitor the hospital network of the Unified Health System.

Preferences of physicians for public and private sector work

BackgroundThe public-private mix of healthcare remains controversial. This paper examines physicians’ preferences for public sector work in the context of dual practice, whilst accounting for other differences in the characteristics of jobs.MethodsA discrete choice experiment is conducted with data from 3422 non-GP specialists from the Medicine in Australia: Balancing Employment and Life (MABEL) panel survey of physicians.ResultsPhysicians prefer to work in the public sector, though the value of working in the public sector is very small at 0.14% of their annual earnings to work an additional hour per week. These preferences are heterogeneous. Contrary to other studies that show risk averse individuals prefer public sector work, for physicians, we find that those averse to taking career or clinical risks prefer to work in the private sector. Those with relatively low earnings prefer public sector work and those with high earnings prefer private sector work, though these effects are small.ConclusionsOther job characteristics are more important than the sector of work, suggesting that these should be the focus of policy to influence specialist’s allocation of time between sectors.

The physician as a neoliberal subject - A qualitative study within a private-public mix setting.

Research on neoliberalism in health care has insufficiently explored the intermediary role of physicians in neoliberal subjectification. This paper studies the construct of the physician as a neoliberal subject in the Israeli health care system, using qualitative data from in-depth interviews with 21 medical specialists. We interviewed physicians from specialties in which private practice is both less common (infectious disease and intensive care) and more common (orthopedics, cardiology, and cardiothoracic surgery). Our analysis focused on two key issues: the physician's role in society and the value placed on health care. We found a spectrum of views. At one end, some perceived themselves as entrepreneurs, managing themselves both as an enterprise and a product, and perceived health care as a commodity. At the opposite end, we found a professional ethos that considered the physician as a public servant, and health care as a human right. Both views were in constant tension with neoliberal subjectivity. Further research should investigate the association between institutional belonging, whether public or private, and the internalization of the main characteristics of the neoliberal worldview.

Tuberculosis Surveillance and Monitoring under the National Public-Private Mix Tuberculosis Control Project in South Korea 2016-2017.

Background The national Public-Private Mix (PPM) tuberculosis (TB) control project provides for the comprehensive management of TB patients at private hospitals in South Korea. Surveillance and monitoring of TB under the PPM project are essential toward achieving TB elimination goals.Methods TB is a nationally notifiable disease in South Korea and is monitored using the surveillance system. The Korea Centers for Disease Control and Prevention quarterly generates monitoring indicators for TB management, used to evaluate activities of the PPM hospitals by the central steering committee of the national PPM TB control project. Based on the notification date, TB patients at PPM hospitals were enrolled in each quarter, forming a cohort, and followed up for at least 12 months to identify treatment outcomes. This report analyzed the dataset of cohorts the first quarter of 2016 through the fourth quarter of 2017.Results The coverage of sputum, smear, and culture tests among the pulmonary TB cases were 92.8% and 91.5%, respectively. The percentage of positive sputum smear and culture test results were 30.7% and 61.5%, respectively. The coverage of drug susceptibility tests among the culture-confirmed cases was 92.8%. The treatment success rate among the smear-positive drug-susceptible cases was 83.2%. The coverage of latent TB infection treatment among the childhood TB contacts was significantly higher than that among the adult contacts (85.6% vs. 56.0%, p=0.001).Conclusion This is the first official report to analyze monitoring indicators, describing the current status of the national PPM TB control project. To sustain its effect, strengthening the monitoring and evaluation systems is essential.

Local inequality and departures from publicly provided health care in Canada.

This paper examines the relationship between changes in income inequality and the provision of resources in a health care system (the public-private mix). Specifically, we investigate whether increases in income inequality, as separate from overall income levels and growth, have changed the availability of both private clinics and privately financed physicians in a context where the dominant market player is the public system. Our findings provide reasonable evidence that increases in income inequality have led to substantial increases in both. We find that moving from median level of inequality across neighborhoods to the top 1% level of inequality increases the probably of a private clinic by 40% and the probability of having physicians who have opted out of the public system by 170%.

Quality of tuberculosis care in the private health sector

As countries move towards achieving universal health coverage, efforts to engage all care providers have gained more significance. Over a third of people estimated to have developed TB in 2018 were not detected and notified by national TB programs (NTPs). This gap is more pronounced in countries with large private sectors, especially those with a high burden of TB. Health care providers outside the scope of NTPs, including the private and informal sector, are often the first point of care for TB patients. However, these providers are not fully engaged despite evidence from country experiences and projects that demonstrate increased detection and good treatment outcomes through publicprivate mix (PPM) approaches. While there are often concerns about quality of care in public facilities, there is also increasing evidence that quality of TB care in the private sector falls short of international standards in many places and urgently needs improvement. Failure to engage the full range of health care providers for TB has serious consequences in terms of access to quality care, resulting in increased transmission as a result of delayed diagnosis and treatment; excess mortality and morbidity as a result of inappropriate treatment; and increased drug resistance as a result of incomplete treatment. Recent attention to this issue has led to significant increases in private TB notifications, especially in India, Indonesia and the Philippines, but the gap between notification and the extension of quality program services for provision of treatment and care appears to be growing.

Cost of seeking care for tuberculosis since the implementation of universal health coverage in Indonesia

BackgroundAlthough tuberculosis (TB) patients often incur high costs to access TB-related services, it was unclear beforehand whether the implementation of universal health coverage (UHC) in Indonesia in 2014 would reduce direct costs and change the pattern of care-seeking behaviour. After its introduction, we therefore assessed TB patients’ care-seeking behaviour and the costs they incurred for diagnosis, and the determinants of both.MethodsIn this cross sectional study, we interviewed adult TB patients in urban, suburban, and rural districts of Indonesia in July–September 2016. We selected consecutively patients who had been treated for TB in primary health centers for at least 1 month until we reached at least 90 patients in each district. After establishing which direct and indirect costs they had incurred during the pre-diagnostic phase, we calculated the total costs (in US Dollars). To identify the determinants of these costs, we applied a general linear mixed model to adjust for our cluster-sampling design.ResultsNinety-three patients of the 282 included in our analysis (33%) first sought care at a private clinic. The preference for such clinics was higher among those living in the rural district (aOR 1.88, 95% CI 0.85–4.15, P = 0.119) and among those with a low educational level (aOR 1.69, 95% CI 0.92–3.10, P = 0.090). Visiting a private clinic as the first contact also led to more visits (β 0.90, 95% CI 0.57–1.24, P < 0.001) and higher costs than first visiting a Primary Health Centre, both in terms of direct costs (β = 16.87, 95%CI 10.54–23.20, P < 0.001) and total costs (β = 18.41, 95%CI 10.35–26.47, P < 0.001).ConclusionDespite UHC, high costs of TB seeking care remain, with direct medical costs contributing most to the total costs. First seeking care from private providers tends to lead to more pre-diagnostic visits and higher costs. To reduce diagnostic delays and minimize patients’ costs, it is essential to strengthen the public-private mix and reduce the fragmented system between the national health insurance scheme and the National TB Programme.

Engaging Community Pharmacies in Early Detection of Missing Tuberculosis Patients through Public-Private Mix Intervention in Pakistan.

Globally, Pakistan ranks fifth in terms of missing tuberculosis (TB) patients' burden. Missed TB cases are either undiagnosed or diagnosed but not notified to the national TB database. Public-private mix interventions are contributing significantly to the case detection, diagnosis, and treatment of TB in Pakistan. However, it is estimated that many cases of infected TB patients go undetected. It is likely that these "undiagnosed" active TB cases seek treatment from community pharmacies, among other venues. This study aimed at assessing the feasibility of community pharmacy-based TB case detection. Case detection protocol implementation in three Pakistani districts in a nonrandom selection of pharmacies was followed by a review of routinely maintained prospective records of patients referred from these private community pharmacies to general practitioner (GP) clinics. The study engaged 500 community pharmacies for referring presumptive TB patients to GP clinics. In total, 85% of the engaged pharmacies remained active in providing referrals during the study period. The community pharmacy-referral network achieved an annual referral rate of 3,025 presumptive TB patients and identified 547 active TB cases for the period January-December 2017. Every fifth referral among presumptives presenting and counseled at pharmacies was diagnosed with TB at GP clinics. This contribution was 9% of all new TB cases identified in these districts through all other private venues linked with the Greenstar Social Marketing setup. Identified barriers and facilitators to implementation and cost effectiveness of pharmacy models for TB case detection should be considered if the model were to be scaled up.