Public-Private-Partnerships Will Help End TB

A Conversation with Dr. Lal Sadasivan of PATH and Dr. Pedro Suarez of MSH

Last year, Tuberculosis claimed the lives of 1.6 million people, and it affects the lives and livelihoods of millions more. While early diagnosis and treatment can cure and prevent the spread of TB, underreporting and under-diagnosis remains a big issue. The 2018 Global TB Report found that of the 10 million who fell ill with TB in 2017, only 6.4 million were officially recorded by national reporting systems. More dangerous yet, growing drug resistance to first-line TB drugs threatens to undermine decades of progress and make treatment both more costly and complex. Still, TB can be eradicated if governments, donors and private sector actors work together to fund and execute an accelerated response to end the TB epidemic.  

On Monday, Sep 24th, in anticipation of the United Nations General Assembly High Level Meeting on TB on September 26, MSH and PATH co-hosted an event ‘Putting Political Will Into Action: Public-Private Partnerships to End TB’, a conversation with Ministers of Health, health system experts, and activists on the need for strong political and financial commitments to end the global TB epidemic. Leading up to the event we brought Dr. Lal Sadasivan, TB Technical Director, HIV/TB Global Program at PATH and Dr. Pedro Suarez, Senior Director, Infectious Diseases Cluster at MSH, together to talk about the importance of greater collaboration between the private and public sectors and the role of health technologies and financing to end TB.

Q: Dr. Pedro Suarez: Lal Sadasivan, in your medical career you’ve always made time to focus on public-private partnerships for TB care and control. In this context, what do we mean when we talk about “the private sector”? And how do public-private partnerships play an important role in ending TB?

A: Dr. Lal Sadasivan: Here we’re referring to private health care providers as “the private sector.” Generally speaking, these would be any care provider who is not directly under the National TB program (NTP). The for-profit private health care providers are the most important sector from the public-private partnership angle.     

In India, for example, 70-80% of people use private-sector facilities when they become sick, and these facilities may also not be following the same standard of care as those recommended by the NTP. So there is a critical need to standardize across sectors and among sectors. Similarly, Indian Railways, a public entity, has 1.4 million employees and with them, their dependents — at least 6 million people. But those employees and their families don’t fall under the network of national or state health services. The health care they receive would be considered private-sector, and these types of providers were not adhering to national TB policies — the policies of the NTP, that is.

One way to harmonize care is through effective partnerships between the private and public sector providers. Without them, we will not be able to find those missing cases, control costs, ensure effective treatment and control drug resistance.

Q: Dr. Pedro Suarez: In your experience, what does a successful, functioning public-private partnership look like on a country level? Do you have any examples of how best to incentivize the private sector to work on TB?

A: Dr. Lal Sadasivan: In a successful private-public partnership model, the non-public health sectors will be able to promptly diagnose and treat TB cases based on standard guidelines and notify them to the NTP. Such models should include 1) a real partnership between NTP and private sector where the partners are considered stakeholders of equal status, 2) the public sector NTP acts as a steward, and not a custodian, of TB control which only policies of the private sector, 3) public sector or outsourced agencies take care of the public health functions in TB control for the TB patients managed by the private sector, 4) TB patients get standard and free/subsidized diagnosis and treatment close to their residence in a friendly environment.

Incentives need not be only financial incentives. Social recognition, licensing, branding, etc. can also be incentives. When it comes to financial aspects, more than adding incentives, avoiding unnecessary interference in the financial transactions in the private sector will help in building trust in the private sector. From our experience in the city of Mumbai, making diagnostics and drugs free of cost or at subsidized rates for patients works as an indirect incentive to the private care provider. Feedback and information about each patient until the treatment outcome is reported is another such incentive.    

Q: Dr. Lal Sadasivan: Pedro, much of your work in TB has focused on strengthening systems for TB through the use of different health technologies. What role does data and technology play in ending TB?

A:  Dr. Pedro Suarez: From a disease surveillance perspective, we know that gaining control and ending the TB epidemic will require the collection of accurate data, the translation of that data into usable information, and getting that information into the hands of the right people at the right time to make informed decisions. Advances in technology and connectivity can now make this possible, but the information systems and technology currently in place in many high-TB burden countries can’t meet the current needs.

Part of strengthening national health systems to deal with TB is incorporating the right technologies that will help them get an edge on the disease. Of course, there are many challenges in getting there – including a lack of appropriate staff and sufficient financial support. Getting high-quality digital technology and information systems in place is going to require cooperation across implementing programs, donors, countries, and private sector actors.

Q: Dr. Lal Sadasivan: What are some technologies that you think hold the most promise? What are some of the challenges?

A:  Dr. Pedro Suarez: A few things. Current information systems are often disconnected and frequently paper-based. The data critical for case finding, contact tracing, case management, and follow-up are not integrated in a single place, and information from the private sector is often not captured. For example, we need better, integrated digital systems that can help ensure treatment adherence for patients with TB.

With support from USAID, MSH created e-TB Manager, a web-based software program that manages the information needed by national TB control programs. It integrates data across most aspects of TB prevention and care and helps more efficiently manage cases of drug resistant-TB. It’s also important to support pharmacies in their efforts to prevent stock-outs of TB drugs and other medicines. We’ve built two other tools to help with that. One is called RxSolution, a computerized management system designed to help pharmacies address stock management challenges and the other one is QuanTB, an electronic quantification and early warning system designed to improve procurement, ordering, and supply planning for TB treatment.

We’ve also witnessed important technological advances in TB testing. In Angola, Afghanistan, Bangladesh and other countries where it has been introduced, the use of GeneXpert machines for rapid TB testing has helped to close gaps in TB diagnosis and treatment by improving the speed and accuracy of sample analysis, and ultimately, save more lives.

Q:  Dr. Pedro Suarez: What are the challenges of working with the private sector? Can we end TB without the private sector? Why or why not?

A: Dr. Lal Sadasivan: Well, the challenges are not just TB-specific. The private sector is heterogeneous, diverse, disorganized and provides services of varying quality. There are multiple agencies and interests that have influence over the private sector. At the same time, there is practically no agency that oversees the private sector as a whole. This makes it difficult for NTP to even start a dialogue with the private sector. The dynamics within the private sector (providers) is seldom explicit nor does it always follow a predictable pattern. The patient pathway, especially related to the private sector, is often unpredictable and unknown to the NTP.   

But no — we absolutely cannot end TB without engaging the private sector. The difficulty that we face in many high-TB-burden countries is that the public sector doesn’t recognize the strength of the private sector and its potential in controlling TB. In many situations, the NTP competes with the private sector for funding and credit. Therefore, the basic approach of the public sector NTP towards the private sector has to change. The importance of the private sector is a growing reality has to be seen as an opportunity and not a threat.

Q: Dr. Lal Sadasivan: What does financial commitment to ending TB look like to you?

A:  Dr. Pedro Suarez: Recently, donors have understood the need for more coordination around digital technology investments. Earlier this year, representatives from donors including USAID, The Global Fund, the Bill & Melinda Gates Foundation, EU, WHO, World Bank and other national, intergovernmental, and private donors came together to create the Digital Investment Principles to guide donor investment in digital systems.

This step forward from the donor community shows the importance of putting high-quality digital technology and information systems in place and will take cooperation across implementing programs, donors, countries, and private sector actors.

Investing in the development of frameworks and connecting existing technologies seems daunting and expensive. It will require ongoing funding, human-centered design, and discussion with public and private sector stakeholders, but in the long run, the benefits will outweigh the costs. Investing the time and funding now, will move all of us forward together around a common framework to ensure that we build systems we’ll be using for years to come.