Publication Year 28 Aug 2023

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Executive Summary

Private sector engagement needs to be urgently expanded to reach End TB targets
TB is preventable and curable, but current efforts to find, treat and cure everyone who gets ill with the disease fall short. Of the 10 million people who fell ill with TB in 2019, only 7.1 million were officially notified to national authorities and reported to WHO. In 2019, 56% of the 2.9 million “missing people” with TB were in seven countries in which private providers accounted for more than two thirds of initial careseeking: Bangladesh, India, Indonesia, Myanmar, Nigeria, Philippines and Pakistan. However, in these countries, private for-profit providers contributed just 28% of total TB notifications, equivalent to only 20% of estimated TB incidence in 2019. These seven countries have been designated as the “Big Seven” PPM priority countries(1). Since 2015, the total number of private for-profit TB notifications in these countries has increased nearly three-fold to more than 1.1 million. While this progress is promising, the challenge now is to further increase case-finding while extending the full package of publicly funded, quality-assured TB services to these private patients. The COVID-19 pandemic has also put gains at risk with a 21% drop in notifications across 84 countries in 2020 – including in several PPM priority countries.
Closing gaps and ensuring early access to diagnosis and treatment will require strengthened and expanded private provider engagement. Engaging private providers is also essential for reducing unnecessary deaths and suffering caused by inappropriate treatment, slowing the emergence of drug resistance caused by substandard care, reducing transmission by shortening delays to treatment, reducing catastrophic costs and impoverishment, and accelerating uptake of new tools.
As countries move towards Universal Health Coverage (UHC) and towards reaching the TB-related targets in the Sustainable Development Goals and End TB Strategy, they need to harness the full potential of private providers. TB programmes can be pioneers in this area by accelerating the strategic engagement of private health care providers. Access to essential TB services across both the public and private sectors should be ensured especially in emergencies such as the COVID-19 pandemic.

Moving from Policy to Practice: We know how to do it
The need to engage private healthcare providers for TB has been acknowledged since the early 1990s and has featured briefly in many global and national strategies and plans since 2001, including the recent WHO End TB Strategy and the Stop TB Global Plan to End TB. Since 2002, WHO has issued and revised a dozen guidance documents addressing various aspects of Public-Private Mix, including how to engage private providers, how to advocate and plan for their engagement, and how to measure progress. Published literature on private provider engagement has increased significantly: a systematic review in 2015 found 78 studies, covering 48 projects in 15 countries (2). Much has been learnt about how to successfully engage private providers for TB care, although there remains considerable room for adaptation and innovation. However, this issue has not had priority or investment commensurate with the scale of the problem. Several countries have begun to slowly take public-private mix approaches to scale, yet private provider engagement (PPE) has been one of the most difficult TB technical areas to move from donor to domestic funding.
A root cause of this has been a strong public sector preference among those who manage TB programmes and those who fund them. It also reflects the ongoing journey, not specific to TB programmes, in which the public sector only gradually gains capacity to govern private health providers effectively, as countries develop. In recent years, a changing mindset towards the private sector has been evolving, Engaging private health care providers in TB care and prevention: a landscape analysis, second edition vi with countries such as India, Bangladesh, Myanmar and Pakistan achieving significant scale in private provider engagement.
In these countries, engagement of large numbers of private primary care providers has been led by strong non governmental organizations (NGOs) acting as intermediaries between providers and National TB Programmes (NTPs). Recently, India has begun to demonstrate unprecedented commitment to engaging private providers by setting ambitious targets (2 million private TB notifications per year by 2020), allocating substantial budgets and mobilizing strong political support at all levels. The Philippines and Indonesia, which had previously focused attention on engaging relatively small numbers of high-volume private hospitals, have recently begun to expand engagement of private primary care providers and redouble efforts to leverage social health insurance schemes. Indonesia is pursuing a model based more on engagement directly from the public sector to private providers with the support of professional associations, rather than using other intermediary organizations.

Strengthening private provider engagement: What more is needed
Support for private provider engagement by external technical and financial partners of NTPs should be based on an appreciation of underlying systemic constraints as well as proximal determinants. There is a role for guidelines, plans, strategies and pilot projects, but they need to be complemented by efforts to increase basic understanding of patient and provider behaviors and of approaches to exercising stewardship over the whole health sector. On the public sector side, it is important to build system capacities for strategic purchasing for both curative and public health services: mandatory notification decrees and other regulatory approaches have a role, but most effort should go into the development and deployment of enablers and motivators to encourage private provider participation. On the private side, there is usually a need to empower intermediary organizations capable of engaging and aggregating large numbers of private providers on behalf of the program, at least until such time as social health insurance or other large-scale purchasing platforms are developed and mature.

Emerging opportunities for increased engagement
Recent increases in notifications are largely driven by high level commitments made at the 2018 UN High Level Meeting on TB and through initiatives such as the WHO Director General flagship initiative Find. Treat. All. #EndTB (with the Global Fund and the Stop TB Partnership), the Global Fund’s strategic initiative to find an additional 1.5 million people with TB by the end of 2019, and with continued support from the US Agency for International Development (USAID) in countries and at the global level. The recent 2020 progress report on TB by the UN Secretary General also highlights the importance of private sector engagement in its priority recommendations.
Several developments could facilitate a major increase in private provider engagement for TB in the coming years. Success in India, Bangladesh or Pakistan could set an example for other countries and inspire them to be more ambitious. The digital revolution is finally reaching TB: new digital technologies facilitate the engagement of private providers by transitioning from paper-based data to digital, case- based registration systems. Such systems enable additional innovations that further facilitate private provider engagement at scale, such as digital vouchers for drugs and diagnostics, adherence monitoring technologies, and digital payment of incentives and enablers to both patients and providers. Access to new and improved diagnostic and treatment tools, such as digital chest x-rays with AI-based tools, Xpert MTB/RIF and shorter, all-oral MDR-TB regimens, and digital adherence technologies, has increased the potential value to private providers of engaging with the public sector. Social health insurance schemes in some countries are approaching full population coverage and will provide an opportunity to drive quality of TB care in the private primary sector. Both social health insurance expansion, and the UHC movement in general, are also increasing the awareness of the need to engage private providers in order to reach true UHC.
The COVID-19 pandemic has been a big setback to TB prevention and care efforts, with substantial impact on public and private notifications in many countries. Data compiled by WHO from 84 countries indicates that an estimated 1.4 million fewer people received care for tuberculosis (TB) in 2020 than in 2019 – a reduction of 21% from 2019. In the group of 10 high-burden countries with the largest reported shortfalls compared with 2019, the overall shortfall was 28%. WHO estimates that these COVID-19 related disruptions in access to TB care could cause an additional half a million TB deaths. TB remains one of the world’s top infectious killers. (3)
The first pressing priority is to catch-up on all the missed patients and offer them TB treatment, in both public and private health sectors. It is also critical to ensure that everyone on TB therapy is adequately supported to complete the full duration of treatment.

A call to action: taking engagement of private providers to scale
Engagement of private providers on a scale commensurate with their importance will require a transformation of the TB response in countries. This will include new partnerships, modern data systems, new payment mechanisms, new skills, and different attitudes.
In 2018, WHO issued a “Roadmap” for TB public-private mix, calling on high-burden countries with large private healthcare sectors, NTPs and their partners to take the following actions (1):

By embracing the lessons learned from nearly 20 years of efforts to engage private providers and taking them to appropriate scale, TB programmes can help drive universal health coverage.