Table 3.

Interventions to improve management of TB in the pharmacy setting in LMICs.

Author	Country and programme	Details of intervention	Key findings/outcomes
Bell et al. [56]	Phnom Penh, Cambodia National center for Tuberculosis and Leprosy Control public/private mix TB Referral Programme	-170 private pharmacies. -Clients with TB symptoms are referred by pharmacy to public sector DOTS clinics. -3-day training for pharmacy staff and visits to DOTS clinics.	During previous 3 months: -One third of the pharmacies reported referring one or more clients. -The 170 pharmacies referred a total of 125 clients. -96% stated they always referred all clients with TB symptoms to DOTS clinics.
Colvin et al. [57]	Kisarawe district, Tanzania National Tuberculosis and Leprosy Programme, PATH, and USAID.	-15 pharmacists (and 15 traditional healers) received 2 days training. -Pharmacies given referral slips and registers to track referrals to DOTS, and directory of DOTS facilities.	-Between 2009 and 2011 smear-positive TB case notification increased from 28 to 47/100,000 -Pharmacies referred 434 people to diagnostic facilities. 97% acted on the referral, and of these, 25% were diagnosed with TB. -New TB case notifications (in the study district) referred through the network ranged from 38% to 70%.
Gharhat et al. [59]	Mumbai, India Mumbai District Tuberculosis Control Society, colleges of pharmacy, professional associations of pharmacists and physicians.	-119 pharmacist -2 interactive workshops -Advised to refer patients with suspected TB and to counsel patients prescribed anti-TB medicines	-Anecdotally, participation in the workshops was associated with a high degree of professional satisfaction. -No measurement of pharmacist performance post training.
Lonnroth et al. [61]; Quy, et al. [63]	Ho Chi Minh City, Vietnam	-150 pharmacies trained according to NTP guidelines -New referral and recording system. -Clients with TB symptoms referred for sputum smear microscopy at a District TB Unit. -US $1 for each sputum-positive detected case	-39% referred at least one client to a TB -310 TB suspects were referred during first 9-month monitoring (only 28% went for testing). -An additional 63 patients were referred and tested in 2nd follow-up. -7% of the 149 patients tested were sputum-positive (accounting for 1.6% of cases detected in the intervention (others resulted from GP and physician referrals).
Mitchell et al. [62]	Santo Domingo, Dominican Republic	-Intervention aimed at pharmacies and local grocery stores -Components of intervention involved a 1 h educational workshop and a motivational ‘detailing visit’ -Participants were invited to sign a pledge and receive a certificate of recognition. -SPs (reporting a set of chronic TB symptoms) were sent 3–6 weeks before the interventions began and again 2–6 weeks afterwards.	-Pharmacies exposed to the intervention improved by 2.12 points (score based on TB behaviours e.g., recognition of symptoms) on average compared with an improvement of 0.9 in the comparison group (p = =0.06) -Half of intervention pharmacies referred SPs directly to the national TB program vs. 18.2% of the control group. -After intervention attempts to sell a medicine including antibiotics without a prescription (e.g., amoxicillin, cephalosporin, rifampicin) fell from 38% of pharmacies to none. -At 6 months follow-up, 33% of pharmacies referred 70 TB suspects of which 7 cases (10%) resulted in a smear positive diagnosis. -At 2 year follow-up, detection of new smear positive cases averaged 150 per quarter vs. 67 per quarter in the pre-intervention period.
Daftary et al. [58]	Patna, India Intervention nested into Universal Access to TB Care (a PPM programme between Bihar state government and PPIA World Health Partners).	-Broader PPM programme involved 554 pharmacies in standardised TB management plus incentive of US $0.75 for each completed referral. -Intervention (105 pharmacies) had 5 additional components: interactive training workshops; referral of TB suspects for chest radiograph and doctor consultation; financial incentives for referral completion, chest radiograph and positive TB diagnosis ($0.75, $1.50, and $3 respectively), text message reminders and field support.	-81% of pharmacy providers actively participated in the pilot vs. 16% in original PPM programme. -Rate of registration of patients with TB symptoms and positive TB diagnoses were 62 and 25 times higher respectively in the intervention group. -Microbiological testing and test confirmation was also significantly higher in the intervention group. -240 additional cases were attributed to the intervention with a cost per case notified of US$100.
Lambert et al. [60]	Cochabamba, Bolivia NTP and local pharmacists association (ASPROFAR)	-A two stage intervention -Phase 1: 170 pharmacists attended a general meeting and local pharmacists association issued a recommendation to members to stop selling anti-TB medicines and refer clients seeking to public services. -Phase 2: 70 pharmacies referred clients with chronic cough to NTP (via referral slip).	-After phase 1, the proportion of pharmacies selling TB drugs decreased (rifampicin: 23–11.5%; isoniazid: 16–3.1%; P < 0.001) and the proportion of pharmacies referring to the NTP clients seeking TB drugs increased (22–58%; P < 0.0001). -In phase two, 38% referred a total of 41 clients for screening in the NTP; 11 of 41 (27%) were screened and of these, 3 (27%), were diagnosed with smear-positive TB.