Public-Private Mix Intervention and its Integration with Community Pharmacies in Detecting the Missing Tuberculosis Cases in Pakistan

Abstract

Tuberculosis (TB) is a major public health challenge in a lower-middle-income country such as Pakistan. Globally, Pakistan ranks fifth in terms of missing TB patients burden. The missed TB cases are either undiagnosed or diagnosed, but not notified to the national TB database. Despite 100% Directly Observed Treatment Short Course Therapy (DOTS) coverage in public sector facilities, 201,528 Tuberculosis (TB) patients are missed each year in Pakistan. These missed TB cases represent a gap between ‘estimated’ annual cases and ‘actual’ annual cases of TB in Pakistan. It is likely that these estimated missed TB cases initiate TB care from providers in the private healthcare system which involves multiple stakeholders including community pharmacies. Whilst 84% of the Pakistani population seek healthcare from private sector facilities, private providers are less motivated to report TB cases to the National TB Control Program (NTP), which leads to significant under-detection of missing TB cases in Pakistan. WHO urges that to mitigate and manage missing TB cases effectively, PPM models are an essential pathway for case detection, referral, diagnostic and treatment pathways. This thesis aims to assess the contribution of conventional PPM and scaled-up PPM models in narrowing the gap between estimated TB cases and incident TB cases at various levels in the healthcare system of Pakistan. The goal of the study objectives is to explore the early case detection of missing TB cases within the Pakistani community. The first study assesses the contribution of existing PPM approaches (private sector) to national TB case notification in comparison to the non-PPM approach (public sector). The recommendation of this study is continued in the form of another study. The latter study is designed at aiming the feasibility of community pharmacy-based TB case detection (PPM-1 boosted) of missing cases in comparison to solo General Practitioner model (conventional PPM-1). For conventional PPM models, a retrospective record review was conducted to explore the proportion of TB cases notified by the four different PPM models implemented in four provinces in comparison to non-PPM models. In the case of scaled-up PPM model, case detection protocol implementation in three Pakistani districts in a non-random selection of pharmacies was followed by the review of routinely maintained prospective vi records of patients referred from these private community pharmacies to General practitioner (GP) clinics. The conventional PPM model was implemented in 92 districts in total with four different approaches and contributed (25%) to national TB case notification (program data of NTP) during the study period. PPM and non-PPM case notification showed a highly significant difference in proportions among compared variables related to gender (p < 0.001), age group (p < 0.000) and province (p < 0.000). Among PPM approaches, GP and NGO facilities achieve the same outcomes as non-PPM, with treatment success of 94%-95% and only 3%-4% not evaluated or lost; private hospitals achieve 82% success because of a total of 14% not evaluated or lost; Parastatals are unable to follow more than half of cases, and therefore achieves a success rate of just 47%. The scaled-up PPM model study engaged 500 community pharmacies for referring presumptive TB patients to GP clinics. In total, 85% of the engaged pharmacies remained active in providing referrals during the study period. The community pharmacies-referral network achieved an annual referral rate of 3,025 presumptive TB patients and identified 547 active TB cases for the period January-December 2017. Every fifth referral among presumptives presenting and counseled at pharmacies was diagnosed with TB at GP clinics. This contribution was 9% of all new TB cases identified in these districts through all other private venues linked with Greenstar Social Marketing setup. PPM model findings in Pakistan are considerably consistent with countries that have prioritized PPM for increasing trend (5-56%) in TB case notification to their national TB control programs. Different PPM approaches need to be scaled up in terms of PPM implemented districts, PPM coverage, PPM coverage efficiency and PPM coverage outcome in the Pakistani healthcare system in the future. Community pharmacies offer a useful resource for scaling-up PPM models of TB care in countries like Pakistan with a fragmented but large private sector. An in-depth investment involving well-thought through recruitment criteria, sampling frame development, comprehensive training followed by setting up a referral mechanism at community pharmacies appeared to lead to a feasible approach in detecting missing TB cases in the Pakistani community/healthcare system. However, sustainability and non-provision of incentives to community pharmacies are potential barriers for their active participation in Scaled up PPM model.