An assessment to generate rich information on key private stakeholders, institutions and providers involved in managing TB cases in six major cities of Nepal and their engagement in testing, treating and tracking tuberculosis in Nepal along with their current care practices for TB patients, especially in the private healthcare sector and design interviews to improve the quality of care.
Tuberculosis (TB) remains one of the major public health problems in Nepal. Just like in many other countries with incomplete coverage of surveillance system, there is considerable uncertainty about number of TB cases and death in Nepal.
TB incidence was estimated to be 152 per 100,000 in 2017 or 45,000 (39,000-50,000) cases. Recently on March 24, 2020, NTC released Nepal National TB Prevalence Survey brief that suggested that “around sixty-nine thousand, 69,000 (41,000 – 103,000) people developed TB in 2018. The brief also suggested that “around one hundred and seventeen thousand, 117,000 (88,000 – 145,000) people with TB disease are living in Nepal today”.
While this is the current situation, National Tuberculosis Control Centre in 2016 had framed 5-year National Strategic Plan (NSP) to make remarkable advancements to meet the global TB elimination target by 2050, in line with the goals, targets and milestones of End TB Strategy as recommended by World Health Organisation (WHO). The NSP aims to decreasing TB incidence by 20% by 2021 which is planned to be done by identifying and managing 20,000 more TB cases by 2021 compared to 2015.
Cognizance of the fact that the initiatives of the government or the National Tuberculosis Program alone can’t suffice to yield desired outputs, the coordination and collaboration across private sectors (hospitals, medical colleges, polyclinics, pharmacies, laboratories, non-government organisations, etc.) and the a meaningful engagement of private sector in TB control program and community’s engagement in TB care are considered as key interventions. In fact, one of the objectives of NSP is to expand case finding by engaging providers for TB care from the public sector (beyond MoH), medical colleges, NGO sector, and private sector through results based financing (PPM) schemes, with formal engagements (signed MoUs) to notify TB cases. After all, the private sector is often the first source of primary healthcare services.
While ensuring meaningful engagement of private sector is one of the key plans of the strategy, such engagement is yet to take place. On the other hand, presumptive TB patients approaching non-governmental providers which are not engaged with NTP undergo a variety of unnecessary diagnostic tests of varied quality. These patients usually shop around various providers before getting the right diagnosis and anti-TB treatment. Thus, patients incur cost on consultation fees, diagnostic tests and treatment. If the presumptive TB patient approaches a non-government provider which is engaged with NTP, the patient undergoes free sputum microscopy test and if diagnosed as tuberculosis is usually initiated on free anti-TB drugs provided by the program.
Non-government provider engaging with NTP invests in human resources like laboratory technician (time spent on sputum microscopy, program trainings, meetings), DOT provider costs and other indirect costs on space, infrastructure, etc. Since NTP does not provide any grant-in-aid to the non-government provider, the cost recovery is attempted by subjecting the patients to other (other than sputum microscopy) chargeable diagnostic tests like Mantoux test, ultra-sonography/CT-scan, blood tests like ESR, initial consultation charges and for the follow-up stage the consultation charges (6-10 times during course of treatment). These result in unnecessary cost to the patients and treatment delays and increase risk of disease transmission and other untoward consequences and unfavorable outcome of TB disease.
The estimated urban population is 44% (2016). An increasing presence of the private sector usually follows urbanization and so is the case in Nepal in the last two decades. From 1995 to 2008, the proportion of private hospitals grew from 23% of all hospitals to 78%. In 2011, 83% of registered medical practitioners present in Nepal were practicing in the private sector.
To end TB, all TB cases must be identified, treated, reported and contact investigated for TB. Timely identification of each presumptive TB cases, proper diagnosis, treatment and notification of each TB case is requisite for ending TB. Thus, NTC is aiming to design most appropriate strategy to engage private sector in nation’s biggest stride in ending TB.
Assessment of Private Sector for Engagement in Tuberculosis was carried out under the aegis of National Tuberculosis Control Centre (NTCC) and Save the Children Nepal Country Office to assess the private sectors for engagement in tuberculosis.
Report is in the final stage. It will be shared soon.