Engaging the private sector to improve tuberculosis diagnostics and treatment
Bold strategies are needed to address the growing numbers of tuberculosis (TB) and drug-resistant TB (DR-TB) cases globally. Cases of tuberculosis, a major cause of illness and death worldwide, have increased following the lingering impact of the COVID-19 pandemic on health systems. Many people around the world—especially in low- and middle-income countries (LMICs) that bear the highest burden of TB—continue to lack access to diagnostic tools and services, and delays in testing and initiation of appropriate treatment have dire consequences on health outcomes.
The End TB Strategy
Many countries have recognized the impact TB can have on their health systems and have adopted the End TB Strategy, which is the World Health Organization’s (WHO) roadmap to eliminating the disease by 2035. Operationalizing the strategy has meant introducing and expanding use of WHO-recommended rapid diagnostic tests that detect both Mycobacterium tuberculosis (the bacterium that causes TB) and drug resistance to the first-line and second-line drugs used to treat the disease. However, competing health service priorities and limited resources mean that governments must look beyond public sector-provided diagnostic services to private sector-supplied testing services.
Currently, 50% to 70% of patients in LMICs first seek care in the private sector. In India and Pakistan, which account for more than a quarter of all global TB cases, engagement of private sector laboratories will enable national TB programs to reach new patients and utilize additional resources. Tapping into the existing infrastructure and resources private sector laboratories possess provides greater availability of resources for TB control efforts and improved potential for financial sustainability. In recognition of the important role the private sector can play to support the End TB Strategy, in 2022 the WHO released guidance for national TB programs to engage with both the public and private sectors in TB prevention and treatment. Depending on the context, this may necessitate finding innovative new partnership models that align incentives in mutually beneficial ways, to ensure that patients are the ultimate beneficiaries with higher quality, but lower cost, testing services that lead to accurate treatment regimens.
IDDS’s pilot initiatives
Approaches to engage private sector laboratories were conceptualized and piloted through USAID’s Infectious Disease Detection and Surveillance (IDDS) project, led by ICF. In India’s Hisar district in the northern state of Haryana, home to some 2 million people, IDDS worked with the national TB program to engage a private laboratory to support timely TB testing for patients served by community-level health facilities. As part of the activity, IDDS identified and integrated 44 private facilities into the newly developed “one-stop” TB testing model, bolstering the diagnostic network.
I was fortunate to be in India as part of the planning meetings between national and state governments and the private sector. The excitement was immense, with the chief medical officer for Hisar noting, “The work in Hisar has the potential to change Hisar, India, and even the world.” Another stakeholder wondered, “Why do patients need to move between sites to be screened; this doesn’t happen for other activities, so why not also replicate this for TB?”
Preliminary results show that the new model increased access to rapid TB tests (specifically, rapid molecular testing) from 26% to 63% and drastically reduced the waiting period for patients to receive their test results.
Similarly, in Pakistan, 70% of people with TB seek care from the private sector, which encompasses more than 70,000 separate providers. This provides the national TB program with an immense challenge: how to gather TB testing data from private laboratories to support national resource allocation and planning and ensure that patients served by private providers are linked to accurate treatments. As it stands, Pakistan has the fifth highest TB burden in the world and the fourth highest DR-TB burden. IDDS has supported diagnostic network assessments in more than 10 countries, including Pakistan, gathering information, and collating recommendations on where and how to engage private sector laboratories in support of TB control efforts.
Choosing a private sector partnership
As countries consider partnership models with the private sector to improve TB diagnostics and linkages to treatment, key considerations include:
- How can private sector laboratories procure the diagnostic instruments and supplies needed for TB testing? National TB programs have a role to play in facilitating access to costly diagnostic instruments and supplies such as GeneXpert® instruments, line probe assay, culture or drug susceptibility testing platforms, and associated consumables. By pooling procurement across public and private facilities, it may be possible to reduce or waive testing costs to patients. Market-based approaches have also been used in India through the Initiative for Promoting Affordable and Quality TB Tests and in the Philippines through a private sector diagnostics consortium. In both cases, diagnostic developers, suppliers, distributors, and private sector entities work together to ensure mutually beneficial outcomes that also provide subsidized testing costs to patients.
- How can TB specimens be collected, transported, and referred to laboratories for testing? India’s Hisar district model engaged a private laboratory to conduct these activities, while in other cases, the specimens collected at private facilities may be transported to and tested in public reference laboratories. For the latter, ensuring that feedback loops exist to report test results back to providers promptly is important for initiating treatment.
- How can private sector facilities and laboratories report results to national and international surveillance systems? Reporting TB test results to clinicians and patients allows timely and accurate treatment, but it is also important to report them to national and international disease surveillance systems, ideally, directly from diagnostic instruments. This allows decision makers to observe hot spots and other epidemiological trends and effectively target education and outreach programs, promote timely testing, allocate financial and other resources to support TB control efforts, and provide the national TB program with greater oversight into the varying quality of diagnostic services across private laboratories—a challenge that must also be overcome to ensure TB patient outcomes improve over time.
Potential replicable success
The global push for universal health coverage has brought greater focus on health service integration across diseases to maximize existing, limited resources. Greater engagement and networking with the private sector provide a path for national TB programs to expand access to diagnostic resources, while governments gain access to information on the epidemiology of the TB and DR-TB epidemic in their own countries as patient TB disease profiles are aggregated through connected national health information systems.
Ultimately there is potential to improve health outcomes and reduce costs along the entire diagnostic cascade, from referring patients or samples for testing to linking laboratory results with service providers and patients with accurate treatment regimens. The success of the IDDS-supported “one-stop” Hisar model pilot shows the feasibility of expanding the pilot to other parts of India, while providing an approach that other countries can replicate.
