Collaboration between private pharmacies and national tuberculosis programme: an intervention in Bolivia

BACKGROUND: Public-private partnerships are felt to be necessary for tuberculosis (TB) control in some developing countries. OBJECTIVES: To evaluate the potential of a collaboration between the National TB Programme (NTP) and private pharmacies in Bolivia, the country with the highest TB incidence in Latin America. METHODS: We contacted the local Pharmacists' Association in the city of Cochabamba, and designed a two phase intervention. The objectives of the first phase were to decrease the availability of TB drugs in private pharmacies on a voluntary basis, and to improve referral of clients seeking TB drugs to the NTP. A survey of all pharmacies allowed for a before-after comparison with a baseline survey. The objectives of the second phase were to obtain referral of pharmacy clients with chronic cough for TB screening in the NTP. This phase was started in 70 pharmacies and evaluated after 2 months using the referral slips issued by the pharmacists. RESULTS: 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 the second phase, 26 of 70 pharmacies (38%) referred a total of 41 clients for screening in the NTP (i.e. an average of 0.29 clients per pharmacy and per month); 11 of 41 (27%) were screened and three of 11 (27%) diagnosed with smear-positive TB. CONCLUSION: The first phase of the intervention proved effective in reducing the availability of the main TB drugs in pharmacies, and in improving referral of clients seeking TB drugs. Key factors in this success were not specific to Bolivia, and collaboration between private pharmacies and public services appears possible in that respect. However, collaboration with pharmacies does not seem an efficient way to increase the number of patients screened for TB, and to shorten delays to TB diagnosis and treatment.     

Anti-tuberculosis treatment in private pharmacies, Kathmandu Valley, Nepal.

SETTING: Urban municipality of 150000 citizens in Kathmandu Valley, Nepal. OBJECTIVE: To determine 1) the perceptions among private pharmacists of characteristics of tuberculosis (TB) patients visiting private pharmacies in the area, 2) the sales of different anti-tuberculosis drugs, and 3) the interaction between private health providers and pharmacists. DESIGN: Between January and April 1998, semi-structured interviews were conducted with 98% (49/50) of the private drug-retailers in the area. RESULTS: Thirty-two (65%) pharmacies had sold anti-TB drugs during the last month. Forty-three (88%) said that most TB patients were of low socio-economic status and rarely bought drugs for more than a week at a time. Only eight (16%) reported that TB patients usually returned to buy the full course of drugs. Seventy-two per cent of total spending on anti-tuberculosis drugs was for different kinds of combinations of drugs. Nine per cent was spent on plain rifampicin, believed to be sold only to tuberculosis/leprosy patients. During the previous month, 5/13 (38%) of pharmacies with no doctors attached had sold anti-tuberculosis drugs compared with 27/38 (71%) of pharmacies with doctors attached to them (P < 0.05). CONCLUSION: The private sector offers an available and acceptable but non-affordable service for many TB patients. A substantial amount of anti-TB drugs are being sold in the private pharmacies. There is therefore a potential role for pharmacists to play in collaborative efforts between the private and public sector in TB control activities.     

An assessment survey of anti-tuberculosis drug management in Cambodia.

SETTING: One hundred and seven public health facilities with tuberculosis (TB) service and 66 private pharmacies in 14 provinces. OBJECTIVES: To assess the knowledge, attitudes and practices (KAP) of TB service providers, new smear-positive pulmonary TB out-patients and drug storekeepers, to document practices in the public sector TB drug procurement system, to measure TB drug availability in private pharmacies and to compare public and private sector TB drug prices with international prices. DESIGN: Documents and treatment record reviews, inventory checks and structured interviews. RESULTS: The prescribing practices of the TB service providers were acceptable. The level of new smear-positive TB out-patients' knowledge of TB treatment was high. The storekeepers' inventory practices for TB drugs indicated a need for improvement. Various TB drugs were available in the private pharmacies. TB drug prices in the public sector were similar to international reference prices, although they were higher than the Global TB Drug Facility prices. CONCLUSIONS: An indicator-based anti-tuberculosis drug management assessment survey can measure the current situation and quality of DOTS, identify any weaknesses or changes in practice from the norm, and simultaneously serve as a basis for training of TB service providers and storekeepers.     

Patient and health system delays in the diagnosis of tuberculosis in Southern Thailand after health care reform.

SETTING: Seven public hospitals in a southern province of Thailand. OBJECTIVES: To measure delays in tuberculosis (TB) diagnosis and to examine the factors associated with these delays, with special focus on the effect of drug store utilisation and health insurance coverage on patient delay. DESIGN: A total of 202 newly diagnosed smear-positive and smear-negative pulmonary TB patients were interviewed using a structured questionnaire. RESULTS: The median patient, health system and total delay were 4.4, 2.8 and 9.4 weeks, respectively. Risk factors for patient delay were age 31-60 years, having mild illness, previous similar symptoms and first presenting to non-qualified providers. Health insurance was not associated with a shorter patient delay. Health system delay was significant longer for patients with health insurance and first presenting to low-level public health facility (i.e., community hospital, health centre, primary care unit or private clinic/hospital). CONCLUSIONS: The public should be informed how to recognise TB symptoms to shorten patient delay. The Thai National Tuberculosis Control Programme needs to supervise the private health sector, including drug stores, for better TB control. Drug store personnel need to be trained to recognise and refer TB suspects. The capacity of low-level public health facilities and private doctors in TB diagnosis needs improvement. A proper referral system should be developed.     

Research Letter: Antihypertensive Drugs Market in India: An Insight on Size,Trends, and Prescribing Preferences in the Private Health Sector, 2016–2018

Background:India has a high burden of hypertension. While the private sector provides 70% of out-patient care in the country, a significant proportion of patients seeking care from the public sector buy drugs from private markets. This study aimed to describe India’s private sector antihypertensive drugs market at the national and state levels over 2016–2018.Methods:Antihypertensive drugs sales in India from 2016–2018 were analysed using a large nationally representative dataset for the private pharmaceuticals market. In addition, data for five states (Punjab, Madhya Pradesh, Kerala, Telangana, and Maharashtra) that were the foci of a large hypertension control program were studied.Results:The Indian hypertension drug market grew at a rate of 6.9% from 2016 to 2018 with a total of 21,066 million pills sales in 2018. Single-pill combinations (SPCs) contributed to 39.1% of total sale volumes. The market comprised of 182 different antihypertensive drugs including 134 SPCs. Total volume of sales covered a maximum of 26% of treatment need for the estimated population with hypertension. Two-drug SPCs had the highest market share (36%), followed by calcium channel blockers (18%), beta-blockers (16%) and angiotensin receptor blockers (14%). Among SPCs, amlodipine+atenolol had highest sales (9.8%). Twenty-five drugs, a mix of single drugs and SPCs, accounted for 80% of total sales. There were large state-to-state variations in sales per capita, preferred therapeutic classes and drugs.Conclusions:Despite the large antihypertensive drugs market, there exists a high unmet need for treatment in India. Inter-state differences in product sales indicate variable treatment practices, underscoring the need for private sector engagement to improve hypertension care practices aligned with national and international guidelines. SPCs contributed to a large share of the private market and inclusion of select antihypertensive SPCs in the national list of essential medications should be considered for the public health system.     

The private-public divide: impact of conflicting perceptions between the private and public health care sectors in India.

SETTING: India's private health care sector manages half the nation's tuberculosis (TB) patients, accounting for an estimated sixth of global TB cases. While several studies have demonstrated private physicians' dubious diagnosis and treatment styles and lack of cooperation with public physicians, very little is still known about the private sector. OBJECTIVES: Using a detailed questionnaire to randomly survey private and public practitioners in Ahmedebad, Gujarat, India, we quantified perceptions held by each sector. STUDY DESIGN: Cross-sectional survey of private and public physicians. RESULTS: Significant conflicts in perception were found regarding interpretation of general facts, attitudes towards each sector, and effectiveness and social implications of DOTS. We also found that such differences in perception were likely to result in mistrust, differing views on reform propositions, conflicting mindsets about social agendas, and unwillingness to cooperate. CONCLUSION: Our data suggest that reconciliation is attainable by obtaining and distributing unbiased, evidence-based information and exposing physicians to both private and public health care sectors in a professional setting.     

Public-private mix DOTS in the Philippines

The National Tuberculosis Prevalence Survey done in 1997 (1997 NPS) revealed that the magnitude of tuberculosis in the Philippines hardly declined between 1982 and 1997. In 1996, the National TB Control Program (NTP) adopted the directly observed treatment short-course (DOTS) strategy. By the end of 2001, more than 90% of the population have access to it. Cohort analysis revealed good treatment outcomes. Despite this improvement in the public sector, there is a concern that the epidemiological impact of DOTS will be limited due to the non-participation of the private practitioners, a major stakeholder. Public-private sector collaboration in TB control was strengthened since the Philippine Coalition Against TB (PhilCAT) was organized in 1994. There are four areas of collaboration, namely, policy development, advocacy and information dissemination, training and research and service delivery. Four models of public-private mix (PPM) DOTS in service delivery were developed. The private DOTS clinics provide the space, staff and operational funds while the Department of Health (DOH) provided technical assistance, anti-TB drugs, laboratory supplies and forms. Evaluation showed that PPM in TB control is feasible with good results. The major challenge is to replicate and institutionalize the PPM DOTS.     

The goal to end TB- strategy: Public private partnership. Is it only private sector to blame?

National Strategic Plan for tuberculosis care and control, Nepal ( 2016-2021) envisions ambitious target of decreasing TB incidence by 20% by 2021.In achieving so it has to identify and manage 20,000 more cases by 2021 compared to 2015. Contribution of private sector which roughly accounts to 25% of all the burden of tuberculosis cases in Nepal will be vitally important along with effective public private partnership. In this review we discuss why blaming the private sector alone is not sufficient and much effective PPP collaboration needs to be done stepping on the positive results shown by the earlier collaboration.     

Joining the DOTS in Bali: private practitioners' perceptions of tuberculosis control.

SETTING: The Indonesian island of Bali has both a national public tuberculosis (TB) programme and a significant private sector that provides treatment for patients with TB. OBJECTIVE: To explore private practitioners' perceptions of barriers to the treatment of patients with TB in Bali to inform strategies for future programme development. DESIGN: Semi-structured interviews were conducted with private practitioners who treated TB patients in their private practice. RESULTS: The main barriers to improved TB control in Bali identified by private practitioners reflect difficulties encountered within the following four areas: patient nonadherence to treatment, limitations of public services, public-private integration and limitations of private services. Private practitioners identified the need for improvements in the level of community education regarding TB, the degree of public-private interaction, the quality of diagnostic services and practitioner access to training. CONCLUSION: This study identified both strengths and weaknesses for TB control in the private sector, as well as considerable variations in perceptions and practice among private practitioners. The development of strategies to address these difficulties and utilise the inherent strengths of both public and private practitioners will be essential for improved service provision and TB control in Bali.     

Planning for PPM-DOTS implementation in urban slums in Kenya: knowledge, attitude and practices of private health care providers in Kibera slum, Nairobi.

SETTING: Kibera, the largest slum in Nairobi, Kenya. OBJECTIVE: To determine the tuberculosis (TB) knowledge, attitude and practices (KAP) of private health care providers (PHCPs) to identify their training needs and willingness to participate in a National Leprosy and Tuberculosis Control Programme (NLTP) guided TB control effort in the slum. DESIGN AND METHODOLOGY: A cross-sectional survey. The KAP of PHCPs was assessed using an interviewer administered questionnaire. RESULTS: Of 75 PHCPs interviewed, the majority (96.0%) were paramedics; 51 (77.1%) did not consider sputum smear microscopy crucial in patients presenting with prolonged cough or when a chest X-ray was suggestive of TB; of 29 (38.7%) who indicated familiarity with the drugs used in TB treatment, 20 (58.5%) would have chosen the NLTP-recommended regimens for the treatment of the various types of TB; 16 (21.3%) PHCPs indicated that they treated TB, six (37.5%) of whom were not familiar with anti-tuberculosis drug regimens. All the PHCPs referred TB suspects to the public sector for diagnosis. CONCLUSION: This study reveals a significant gap in TB knowledge among the PHCPs in Kibera slum. However, given appropriate training and supervision, there is potential for public-private mix for DOTS implementation in this setting.     

Improved tuberculosis case detection through public-private partnership and laboratory-based surveillance, Kannur District, Kerala, India, 2001-2002.

BACKGROUND: Efforts to intensify global tuberculosis (TB) control are limited by difficulties in coordinating with private doctors. More than half of Indian TB patients may initially consult a private provider, but many are neither diagnosed accurately nor treated effectively. We established and evaluated a public-private partnership based on surveillance of TB detected in private laboratories and use of standardised directly observed treatment regimens. METHODS: In one district, the governmental TB control programme offered training in microscopy to all large private sector laboratories, and educated private physicians on the importance of microscopy for TB diagnosis. We reviewed records from participating private laboratories and all publicly diagnosed patients. RESULTS: Of 2328 pulmonary TB patients registered from July 2001 to December 2002, 404 (17%) were detected in the private sector. The annual new AFB-positive case notification rate increased by 21%, from 27.8/100,000 in 2000 to 33.5/100,000 in 2002. Surveillance at private laboratories found an additional 260 nonregistered AFB-positive patients. CONCLUSIONS: This public-private partnership substantially increased TB case detection and established a sustainable framework for private sector involvement in TB control. In the setting of a strong public sector programme, the combination of active surveillance of private laboratories along with physician sensitisation is a promising approach to improve TB case detection.     

Notification of patients with tuberculosis detected in the private sector, Tehran, Iran.

OBJECTIVE: To determine the case notification rate of patients with tuberculosis (TB) detected by private laboratories, in Tehran, Iran. STUDY DESIGN: Cross-sectional study. METHOD: All confirmed TB cases among suspected cases referred to private laboratories for acid-fast bacilli (AFB) examination in 2002-2003 were enrolled in the study. All AFB-positive cases were followed up for notification to the Iranian Ministry of Health (MOH) National Tuberculosis Programme (NTP). RESULTS: Of the total number of cases referred to private laboratories, 646 AFB-positive cases were followed up. Of these, 317 (49.1%) cases were female and 328 (50.8%) were male; the mean age was 52.2 years (SD +/- 21.7). Patients were contacted either at their residence or by telephone: 82 were found to be registered with the MOH while 564 (87.3%) could not be traced. A positive correlation was detected between physician advice for patient referral to health centres and case registration by the MOH (Fisher's Exact test 0.000). CONCLUSION: The private sector in Tehran plays a significant role in TB detection, but there are major gaps in the collaboration between the private and public health systems.     

Drugs in the parallel market for the treatment of urethral discharge in Dakar: epidemiologic investigation and physicochemical tests.

OBJECTIVE: Sexually transmitted diseases (STDs) constitute a major public health concern in developing countries. Their interest lies mainly in their diagnosis and their early treatment. Owing to lack of health education and poor living conditions inherent in underdevelopment, self-medication is common practice in these Third World countries. Therefore, the illegal sale of drugs is an important phenomenon in Africa and Asia. METHODS: An investigation, with a view to evaluating the importance of drug sales in the parallel market for the treatment of urethral discharge in Dakar, was carried out in 50 different locations in the working-class districts of the capital from 13 February to 6 March 1997. These drugs, obtained from vendors in the illegal market, were tested and analyzed using the standard physicochemical methods. RESULTS: The most frequently proposed drugs to treat male urethritis are: ampicillin 250-mg capsules (44%); oxytetracyline 250-mg capsules (24%); and cotrimoxazole 450-mg tablets (12%). In most cases (88%), these drugs were sold unpackaged; 12% were sold in blisters. Furthermore, in 90% of cases, the expiry date was not indicated. The dosage and duration of treatment were correct in only 6% of cases. The physicochemical analysis was based on the external appearance, the identification, and the dosage of the active principle. Of these drugs offered by street vendors, 53.1% had an unusual appearance; they were mainly ampicillin 250 mg (21 of 22 samples) and oxytetracycline 250 mg (6 of 12 samples). Furthermore, all active principles were identified as positive, with the exception of ampicillin 250 mg, for which only one sample of the 22 was positive; the others appeared to be flour, with no trace of the active principle. CONCLUSION: Given the extent of these illegal sales of drug and their harmful consequences for the health of the population, adequate measures should be taken to eradicate this blight. For this mission to succeed, public authorities, health professionals and populations should combine their efforts.     

Referring TB suspects from private pharmacies to the National Tuberculosis Programme: experiences from two districts in Ho Chi Minh City, Vietnam.

SETTING: Ho Chi Minh City, Vietnam. OBJECTIVE: To describe pharmacists' attitudes towards referring TB suspects to the National Tuberculosis Programme (NTP) and to evaluate the feasibility of a new referral system. METHODS: 1) Questionnaire survey of 150 private pharmacies; 2) qualitative interviews with 16 pharmacists; 3) monitoring the use of new referral forms for 21 months. RESULTS: Use of a simple referral form was thought to be manageable by 72% of the pharmacists. Pharmacists identified a number of different types of risks associated with referral of TB suspects to the NTP; clients could turn to another pharmacy (61% of respondents); criticise the pharmacist if it appears that they do not have TB (42%); or remain untreated because they are not able to visit the NTP (41%). Fifty-eight (39%) of eligible pharmacies referred at least one client. At least 373 suspects were referred, 149 were tested and 10 had TB. CONCLUSIONS: It is feasible to let pharmacies refer TB suspects. For there to be a significant impact on case detection, it is important to acknowledge a number of concerns expressed by pharmacists and attempt to change both clients' and providers' expectations with regard to the pharmacists' role.