Meet the patients where they are: A greater ambition for private provider engagement for TB

As tuberculosis (TB) practitioners, we are often focused on guidelines and best practices – how we wish the world would be – rather than how the world is in reality. This is particularly true for the area of TB private provider engagement (PPE). Too many TB stakeholders wish and act as though the public sector were the only important and valued actor in TB prevention and care. But gradually there is a realization that to conquer TB we must deal with the reality of a mixed health system: public and private [1].

As noted in a recent landscape analysis of TB PPE [2], seven of the highest TB burden countries (India, Indonesia, Philippines, Pakistan, Nigeria, Bangladesh and Myanmar), which account for 57% of the global TB incidence and 63% of missing cases [3], have dominant private sectors. Across these countries, private providers are the destination for 75% (67%–84%) of initial care-seeking, and private expenditure represents 61%–74% of total expenditure on health. Yet private for-profit TB notifications represent only 19% (5%–28%) of total TB notifications and 12% (1%–18%) of estimated TB incidence [2]. This disconnect between where patients are and where TB is notified suggests a simple conclusion: A very large proportion of the TB epidemic is hiding in plain sight in these large and thriving private sectors.

Confronted with such figures, there is an unstated yet implicit assumption by some stakeholders: If we ignore private providers in TB today, maybe by tomorrow their role will have withered from neglect. This seems unlikely. Health systems in richer countries typically feature a strong role for the public sector in health governance, but the majority of providers often remains private (this is true in the primary care sectors of 21 of 27 OECD countries, for example [4]). The issue of TB PPE is not going away anytime soon.

So why the disconnect between need and response, despite a long-term interest [5] in promoting TB PPE? The landscape analysis [2] outlines a number of the contributing reasons, including: bias towards public provision (based on ideology, mistrust, self-interest, lack of information and practicality); lack of funding for private provider engagement; lack of understanding of private healthcare markets; greater familiarity with traditional public sector approaches; few champions or orchestrators of system transformation; fragmentation of the private market; weakness of key health systems (such as uneven or unrealistic regulatory enforcement strategies, and strategic purchasing and information systems that are not designed to ease or incentivize the process of PSE); a shortage of experienced and qualified implementers; few inspiring models at scale; challenges specific to TB (including a complex diagnostic pathway and long treatment); market forces that are not aligned with the careful tracking required for good TB outcomes; and more attractive competing priorities in the variety of TB subtopics that also clamor for attention.

From these many challenges, two overarching themes stand out. First, there is not enough attention paid to TB PPE, and that needs to change. With attention comes money, prioritization, investment in technological solutions and more inspiring models, and the availability of more implementers. But second, this area of TB PPE is not a quick or easy fix. Effective governance of the private sector requires a very different skillset in indirect management and influence, which takes time to learn and develop. This is an area that requires long-term and patient investment on a variety of technical fronts to yield results.

The Public-Private Mix (PPM) working group of the Stop TB Partnership has responded with a Roadmap to guide such investments [6]. The Roadmap recommends ten actions at national and global levels to scale up the engagement of all care providers towards universal access to care. According to this roadmap, National TB programs (NTPs) and their partners, in collaboration with the private sector, must:

• i.Build understanding about patient preferences, private sector dynamics and the rationale for engaging all providers
• ii.Set appropriately ambitious PPM targets
• iii.Advocate for political commitment, action and investment in PPM
• iv.Allocate adequate funding for engaging all providers, including by capitalizing on financing reforms for Universal Health Coverage
• v.Partner with and build the capacity of intermediaries and key stakeholders
• vi.Establish a supportive policy and regulatory framework
• vii.Adapt flexible models of engagement applicable to local contexts
• viii.Harness the power of digital technologies
• ix.Deliver a range of financial and non-financial incentives and enablers
• x.Monitor progress and build accountability

The roadmap calls on the TB community at all levels to acknowledge the importance of addressing TB prevention and care by private providers, and to take on the task of TB PPE in a way that involves partnership rather than conflict with those providers. Regulation is one critical aspect, but other approaches such as strategic purchasing may be as or even more important [7]. Throughout, there is a need to focus on both immediate results via direct engagement efforts (based on existing guidance [2], [8], [9]), and on building technology, data and purchasing systems that can expand and maintain PPE efforts in TB and in the health sector in general [1], [10]. With such efforts, TB PPE can lead not only to improved impact of TB prevention and care efforts globally, but also to important health systems reforms in the TB high burden countries.