- Email: [email protected]
Public–private mix in tuberculosis – Authors' reply
Correspondence
for quality care. We tracked patients from outside the intervention area and excluded them from our figures. Indus Hospital’s participation was an important factor in the programme’s success; to capture undiagnosed patients we need recognised brands providing quality health-care, as was the experience in India.4 Thus, the role of Indus Hospital is integral to the intervention that can and should be replicated. At 66%, treatment success was less than ideal in the first two intervention quarters and notably lower than the 90% reported by NTP for the country. NTP-provided drugs were given in accordance with NTP guidelines by project staff at private provider clinics as chosen by the patients. Focused efforts improved success to 72% through the third quarter cohort overall, and 75% in the private clinics, which we hope will continue to improve. Rapid increases in case detection as witnessed in Karachi can overwhelm already stretched clinical, laboratory, and programme staff and drug supply systems. Others considering similar interventions can be better prepared to manage cases, including those who are not symptomatic at the time of diagnosis and experience side-effects from antituberculosis drugs. Suman Saurabh and colleagues raise an interesting point about our lack of screening sensitivity. We agree the combination of screening questions with sputum smear as the diagnostic test has low sensitivity, resulting in many people being missed. An algorithm including digital chest radiography and a rapid molecular test for patients with abnormalities could detect many more cases. As Baloch and Pai1 rightly conclude, the next step is combining innovative technologies with smart business models to allow for sustainable engagement of the private sector. Recently, UNITAID approved US$30 million for WHO and the Stop TB Partnership to accelerate 910
testing with Xpert MTB/RIF (Cepheid, Sunnyvale, CA, USA) in 21 countries and reduce cartridge costs to $9·98. The TB REACH initiative will also contribute $10 million for implementation through grants. Parts of these awards imply developing sustainable partnerships through social enterprise models in Bangladesh, Indonesia, and Pakistan. Unlike social franchising, which depends on donor funding to provide services, social enterprises seek to generate revenue to sustain services. However, unlike traditional businesses, profits from social enterprises are reinvested, improving care and reducing patient costs rather than paying dividends. With initial funding from UNITAID and TB REACH, we believe public– private social enterprise models can improve tuberculosis control, provide new diagnostics free-ofcharge, and potentially oust poor quality diagnostics. We hope to continue this discussion and present results soon. JC and SS work for TB REACH at the Stop TB Partnership. ZY and AK work for Interactive Research and Development, which receives funding from TB REACH.
*Jacob Creswell, Zayed Yasin, Suvanand Sahu, Aamir J Khan [email protected] TB REACH initiative of the Stop TB Partnership, Geneva CH-1211, Switzerland (JC, SS); and Interactive Research and Development, Karachi, Pakistan (ZY, AK) 1
2
3
4
5
Baloch NA, Pai M. Tuberculosis control: business models for the private sector. Lancet Infect Dis 2012; 12: 579–80. Khan AJ, Khowaja S, Khan F, et al. Engaging the private sector to increase tuberculosis case detection: an impact evaluation study. Lancet Infect Dis 2012; 12: 608–16. WHO. Global tuberculosis control 2012. Geneva: World Health Organization. http:// www.who.int/tb/publications/global_report (accessed Oct 17, 2012) Murthy KJR, Frieden TR, Yazdani A, Hreshikesh P. Public-private partnership in tuberculosis control: experience in Hyderabad, India. Int J Tuberc Lung Dis 2001; 5: 354–59. WHO. World health statistics 2012. Part III: Global health indicators. Geneva: World Health Organization, 2012: 133–143. http://www. who.int/healthinfo/EN_WHS2012_Part3.pdf (accessed July 31, 2012).
Authors’ reply Jacob Creswell and colleagues and Gyanshankar Mishra reiterate the importance of private sector involvement in countries such as Pakistan and India, and the need to consider long-term sustainability of public–private mix initiatives in these countries. These colleagues agree with us that technology alone is unlikely to ensure success, and that innovative business models need to be tried.1 Creswell and colleagues reemphasise the importance of partnering with well recognised private hospitals (eg, Indus Hospital in their Karachi project2) to ensure highquality tuberculosis care and referral services for general practitioners, and suggest that this approach can be replicated in other settings. By contrast, Mishra asks how a marketdriven, for-profit private sector can be expected to support public–private mix initiatives, especially when national tuberculosis programmes (NTPs) in countries such as Pakistan and India are underfunded and unable to deliver quality services. These divergent comments raise an important question. Should we rely on the goodwill and enthusiasm of a few committed private sector providers or hospitals, or consider more realistic market-based approaches for which patients continue to pay as they are currently doing in the private sector, but get better value (ie, get quality diagnosis and treatment) for the money that they are spending? In other words, does scope exist for a pure private sector model that is sustainable without donor funding, or even without NTP engagement, since not all NTPs are able to overcome the entrenched barriers and prejudices that prevent them from seriously engaging with the private sector? As Creswell and colleagues point out, patients are often willing to pay for good care, but currently they have no way of separating the good from the bad in unregulated private markets. For example, large numbers
www.thelancet.com/infection Vol 12 December 2012
Correspondence
of patients with tuberculosis in the Indian private sector get tested with antibody-based, serological tests that are now banned by the Government of India.3 Even after the ban, several private laboratories are continuing to offer tuberculosis serology, whereas others have switched to equally bad or worse alternatives such as in-house blood PCR and QuantiFERON-TB Gold for active tuberculosis. So, if patients are paying out-of-pocket for such inappropriate tests, can they instead get a quality-assured, WHO-endorsed test result for the same money? We are pleased that the UNITAID initiative has reduced the cost of Xpert MTB/RIF technology (Cepheid, Sunnyvale, CA, USA) to US$9·98 per cartridge, and that TB REACH will provide implementation grants.4 But it is a matter of concern that the buydown price of $9·98 is not available to private sector providers in countries such as Pakistan and India where affordable, quality tests are needed. For example, the present market price of Xpert MTB/RIF in the Indian private sector is about $50–75, substantially higher than the $10–20 price of tuberculosis serology that needs to be replaced.3 Generally, public–private mix projects including financial incentives and salaries for a larger number of contractual outreach workers might pose challenges for sustainability. For example, despite its success and substantial contribution to increasing case detection, the performance of the Good Life social franchise model in Pakistan decreased unexpectedly at the completion of support from the Global Fund. The main challenge was the sustainability of outreach staff.5 Therefore, we are eager to see if the social enterprise model proposed by Creswell and colleagues will overcome such challenges. We hope it will. NAB is former manager of the National tuberculosis Control Programme (NTP) in Pakistan and is a trustee of Hamara Healthy Living Centre. MP is a consultant for the Bill & Melinda Gates Foundation. The Gates Foundation, NTP Pakistan, and Hamara HLC had no involvement in this comment.
www.thelancet.com/infection Vol 12 December 2012
Noor Ahmad Baloch, Madhukar Pai [email protected] HAMARA HLC, Montagu Avenue, Roundhay, Leeds LS8 3EU, UK (NAB); and Department of Epidemiology & Biostatistics, McGill University & Montreal Chest Institute, Montreal, QC, Canada (MP) 1
2
3
4
5
Baloch NA, Pai M. Tuberculosis control: business models for the private sector. Lancet Infect Dis 2012; 12: 579–80. Khan AJ, Khowaja S, Khan FS, et al. Engaging the private sector to increase tuberculosis case detection: an impact evaluation study. Lancet Infect Dis 2012; 12: 608–16. Jarosawlski S, Pai M. Why are inaccurate tuberculosis serological tests widely used in the Indian private healthcare sector? A root-cause analysis. J Epidemiol Global Health 2012; 2: 39–50. UNITAID. Public-private partnership announces immediate 40 percent cost reduction for rapid TB test. 2012 http://www. unitaid.eu/index.php?option=com_content&v iew=article&layout=edit&id=986 (accessed Oct 8, 2012). Eldred L, Smart T. Studies report challenges and successes in the roll-out out of intensified case finding and IPT. 2010. hƩp://www.aidsmap. com/page/1375829/#item1375826 (accessed Oct 6, 2012).
colleagues1 only 15 (13%) of the 115 patients with previous exposure to antiretroviral treatment developed treatment failure at 12 months. Therefore, rather than giving a different antiretroviral treatment regimen, we propose that these patients should have a viral load test done 6 months after the start of treatment. The problem of monitoring patients on antiretroviral therapy needs to be solved before introducing large-scale testing for pretreatment drug resistance. The use of targeted viral load testing before switching to second-line antiretroviral treatment has major cost-saving potential by avoiding unnecessary switches.4 The availability of a point-of-care viral load test is the priority in low-resource settings.5 Subsequently, such an approach could integrate the detection of key drug-resistant mutations. We declare that we have no conflicts of interest.
Pretreatment HIV-1 drug resistance testing in sub-Saharan Africa We welcome the analysis of Raph Hamers and colleagues1 on the effect of pretreatment HIV-1 drug resistance on first-line treatment outcomes, calling for investment in testing for pretreatment drug resistance in Africa. It is clear that the risk of pretreatment drug resistance will increase as the rollout of antiretroviral treatment continues in Africa.2 However, because of cost, and scarcity of human resources and laboratory infrastructure, it will not be possible in the near future to routinely test for drug resistance in Africa before the start of first-line antiretroviral treatment. Andrew Kambugu in his Comment3 proposes a more pragmatic approach, in which patients with a history of previous exposure to antiretroviral treatment should be offered an alternative first-line regimen. However, in the study of Hamers and
*Lutgarde Lynen, Katrien Fransen, Johan Van Griensven, Robert Colebunders [email protected] Institute of Tropical Medicine, Clinical Sciences, Nationalestraat 155, 2000 Antwerpen, Belgium 1
2
3
4
5
Hamers RL, Schuurman R, Sigaloff KC, et al. Effect of pretreatment HIV-1 drug resistance on immunological, virological, and drug-resistance outcomes of first-line antiretroviral treatment in sub-Saharan Africa: a multicentre cohort study. Lancet Infect Dis 2012; 12: 307–17. Hamers RL, Wallis CL, Kityo C, et al. HIV-1 drug resistance in antiretroviral-naive individuals in sub-Saharan Africa after rollout of antiretroviral therapy: a multicentre observational study. Lancet Infect Dis 2011; 11: 750–59. Kambugu A. Pre-ART HIV resistance testing in Africa: are we there yet? Lancet Infect Dis 2012; 12: 261. Lynen L, An S, Koole O, et al. An algorithm to optimize viral load testing in HIV-positive patients with suspected first-line antiretroviral therapy failure in Cambodia. J Acquir Immune Defic Syndr 2009; 52: 40–48. Calmy A, Ford N, Hirschel B, et al. HIV viral load monitoring in resource-limited regions: optional or necessary? Clin Infect Dis 2007; 44: 128–34.
911
for quality care. We tracked patients from outside the intervention area and excluded them from our figures. Indus Hospital’s participation was an important factor in the programme’s success; to capture undiagnosed patients we need recognised brands providing quality health-care, as was the experience in India.4 Thus, the role of Indus Hospital is integral to the intervention that can and should be replicated. At 66%, treatment success was less than ideal in the first two intervention quarters and notably lower than the 90% reported by NTP for the country. NTP-provided drugs were given in accordance with NTP guidelines by project staff at private provider clinics as chosen by the patients. Focused efforts improved success to 72% through the third quarter cohort overall, and 75% in the private clinics, which we hope will continue to improve. Rapid increases in case detection as witnessed in Karachi can overwhelm already stretched clinical, laboratory, and programme staff and drug supply systems. Others considering similar interventions can be better prepared to manage cases, including those who are not symptomatic at the time of diagnosis and experience side-effects from antituberculosis drugs. Suman Saurabh and colleagues raise an interesting point about our lack of screening sensitivity. We agree the combination of screening questions with sputum smear as the diagnostic test has low sensitivity, resulting in many people being missed. An algorithm including digital chest radiography and a rapid molecular test for patients with abnormalities could detect many more cases. As Baloch and Pai1 rightly conclude, the next step is combining innovative technologies with smart business models to allow for sustainable engagement of the private sector. Recently, UNITAID approved US$30 million for WHO and the Stop TB Partnership to accelerate 910
testing with Xpert MTB/RIF (Cepheid, Sunnyvale, CA, USA) in 21 countries and reduce cartridge costs to $9·98. The TB REACH initiative will also contribute $10 million for implementation through grants. Parts of these awards imply developing sustainable partnerships through social enterprise models in Bangladesh, Indonesia, and Pakistan. Unlike social franchising, which depends on donor funding to provide services, social enterprises seek to generate revenue to sustain services. However, unlike traditional businesses, profits from social enterprises are reinvested, improving care and reducing patient costs rather than paying dividends. With initial funding from UNITAID and TB REACH, we believe public– private social enterprise models can improve tuberculosis control, provide new diagnostics free-ofcharge, and potentially oust poor quality diagnostics. We hope to continue this discussion and present results soon. JC and SS work for TB REACH at the Stop TB Partnership. ZY and AK work for Interactive Research and Development, which receives funding from TB REACH.
*Jacob Creswell, Zayed Yasin, Suvanand Sahu, Aamir J Khan [email protected] TB REACH initiative of the Stop TB Partnership, Geneva CH-1211, Switzerland (JC, SS); and Interactive Research and Development, Karachi, Pakistan (ZY, AK) 1
2
3
4
5
Baloch NA, Pai M. Tuberculosis control: business models for the private sector. Lancet Infect Dis 2012; 12: 579–80. Khan AJ, Khowaja S, Khan F, et al. Engaging the private sector to increase tuberculosis case detection: an impact evaluation study. Lancet Infect Dis 2012; 12: 608–16. WHO. Global tuberculosis control 2012. Geneva: World Health Organization. http:// www.who.int/tb/publications/global_report (accessed Oct 17, 2012) Murthy KJR, Frieden TR, Yazdani A, Hreshikesh P. Public-private partnership in tuberculosis control: experience in Hyderabad, India. Int J Tuberc Lung Dis 2001; 5: 354–59. WHO. World health statistics 2012. Part III: Global health indicators. Geneva: World Health Organization, 2012: 133–143. http://www. who.int/healthinfo/EN_WHS2012_Part3.pdf (accessed July 31, 2012).
Authors’ reply Jacob Creswell and colleagues and Gyanshankar Mishra reiterate the importance of private sector involvement in countries such as Pakistan and India, and the need to consider long-term sustainability of public–private mix initiatives in these countries. These colleagues agree with us that technology alone is unlikely to ensure success, and that innovative business models need to be tried.1 Creswell and colleagues reemphasise the importance of partnering with well recognised private hospitals (eg, Indus Hospital in their Karachi project2) to ensure highquality tuberculosis care and referral services for general practitioners, and suggest that this approach can be replicated in other settings. By contrast, Mishra asks how a marketdriven, for-profit private sector can be expected to support public–private mix initiatives, especially when national tuberculosis programmes (NTPs) in countries such as Pakistan and India are underfunded and unable to deliver quality services. These divergent comments raise an important question. Should we rely on the goodwill and enthusiasm of a few committed private sector providers or hospitals, or consider more realistic market-based approaches for which patients continue to pay as they are currently doing in the private sector, but get better value (ie, get quality diagnosis and treatment) for the money that they are spending? In other words, does scope exist for a pure private sector model that is sustainable without donor funding, or even without NTP engagement, since not all NTPs are able to overcome the entrenched barriers and prejudices that prevent them from seriously engaging with the private sector? As Creswell and colleagues point out, patients are often willing to pay for good care, but currently they have no way of separating the good from the bad in unregulated private markets. For example, large numbers
www.thelancet.com/infection Vol 12 December 2012
Correspondence
of patients with tuberculosis in the Indian private sector get tested with antibody-based, serological tests that are now banned by the Government of India.3 Even after the ban, several private laboratories are continuing to offer tuberculosis serology, whereas others have switched to equally bad or worse alternatives such as in-house blood PCR and QuantiFERON-TB Gold for active tuberculosis. So, if patients are paying out-of-pocket for such inappropriate tests, can they instead get a quality-assured, WHO-endorsed test result for the same money? We are pleased that the UNITAID initiative has reduced the cost of Xpert MTB/RIF technology (Cepheid, Sunnyvale, CA, USA) to US$9·98 per cartridge, and that TB REACH will provide implementation grants.4 But it is a matter of concern that the buydown price of $9·98 is not available to private sector providers in countries such as Pakistan and India where affordable, quality tests are needed. For example, the present market price of Xpert MTB/RIF in the Indian private sector is about $50–75, substantially higher than the $10–20 price of tuberculosis serology that needs to be replaced.3 Generally, public–private mix projects including financial incentives and salaries for a larger number of contractual outreach workers might pose challenges for sustainability. For example, despite its success and substantial contribution to increasing case detection, the performance of the Good Life social franchise model in Pakistan decreased unexpectedly at the completion of support from the Global Fund. The main challenge was the sustainability of outreach staff.5 Therefore, we are eager to see if the social enterprise model proposed by Creswell and colleagues will overcome such challenges. We hope it will. NAB is former manager of the National tuberculosis Control Programme (NTP) in Pakistan and is a trustee of Hamara Healthy Living Centre. MP is a consultant for the Bill & Melinda Gates Foundation. The Gates Foundation, NTP Pakistan, and Hamara HLC had no involvement in this comment.
www.thelancet.com/infection Vol 12 December 2012
Noor Ahmad Baloch, Madhukar Pai [email protected] HAMARA HLC, Montagu Avenue, Roundhay, Leeds LS8 3EU, UK (NAB); and Department of Epidemiology & Biostatistics, McGill University & Montreal Chest Institute, Montreal, QC, Canada (MP) 1
2
3
4
5
Baloch NA, Pai M. Tuberculosis control: business models for the private sector. Lancet Infect Dis 2012; 12: 579–80. Khan AJ, Khowaja S, Khan FS, et al. Engaging the private sector to increase tuberculosis case detection: an impact evaluation study. Lancet Infect Dis 2012; 12: 608–16. Jarosawlski S, Pai M. Why are inaccurate tuberculosis serological tests widely used in the Indian private healthcare sector? A root-cause analysis. J Epidemiol Global Health 2012; 2: 39–50. UNITAID. Public-private partnership announces immediate 40 percent cost reduction for rapid TB test. 2012 http://www. unitaid.eu/index.php?option=com_content&v iew=article&layout=edit&id=986 (accessed Oct 8, 2012). Eldred L, Smart T. Studies report challenges and successes in the roll-out out of intensified case finding and IPT. 2010. hƩp://www.aidsmap. com/page/1375829/#item1375826 (accessed Oct 6, 2012).
colleagues1 only 15 (13%) of the 115 patients with previous exposure to antiretroviral treatment developed treatment failure at 12 months. Therefore, rather than giving a different antiretroviral treatment regimen, we propose that these patients should have a viral load test done 6 months after the start of treatment. The problem of monitoring patients on antiretroviral therapy needs to be solved before introducing large-scale testing for pretreatment drug resistance. The use of targeted viral load testing before switching to second-line antiretroviral treatment has major cost-saving potential by avoiding unnecessary switches.4 The availability of a point-of-care viral load test is the priority in low-resource settings.5 Subsequently, such an approach could integrate the detection of key drug-resistant mutations. We declare that we have no conflicts of interest.
Pretreatment HIV-1 drug resistance testing in sub-Saharan Africa We welcome the analysis of Raph Hamers and colleagues1 on the effect of pretreatment HIV-1 drug resistance on first-line treatment outcomes, calling for investment in testing for pretreatment drug resistance in Africa. It is clear that the risk of pretreatment drug resistance will increase as the rollout of antiretroviral treatment continues in Africa.2 However, because of cost, and scarcity of human resources and laboratory infrastructure, it will not be possible in the near future to routinely test for drug resistance in Africa before the start of first-line antiretroviral treatment. Andrew Kambugu in his Comment3 proposes a more pragmatic approach, in which patients with a history of previous exposure to antiretroviral treatment should be offered an alternative first-line regimen. However, in the study of Hamers and
*Lutgarde Lynen, Katrien Fransen, Johan Van Griensven, Robert Colebunders [email protected] Institute of Tropical Medicine, Clinical Sciences, Nationalestraat 155, 2000 Antwerpen, Belgium 1
2
3
4
5
Hamers RL, Schuurman R, Sigaloff KC, et al. Effect of pretreatment HIV-1 drug resistance on immunological, virological, and drug-resistance outcomes of first-line antiretroviral treatment in sub-Saharan Africa: a multicentre cohort study. Lancet Infect Dis 2012; 12: 307–17. Hamers RL, Wallis CL, Kityo C, et al. HIV-1 drug resistance in antiretroviral-naive individuals in sub-Saharan Africa after rollout of antiretroviral therapy: a multicentre observational study. Lancet Infect Dis 2011; 11: 750–59. Kambugu A. Pre-ART HIV resistance testing in Africa: are we there yet? Lancet Infect Dis 2012; 12: 261. Lynen L, An S, Koole O, et al. An algorithm to optimize viral load testing in HIV-positive patients with suspected first-line antiretroviral therapy failure in Cambodia. J Acquir Immune Defic Syndr 2009; 52: 40–48. Calmy A, Ford N, Hirschel B, et al. HIV viral load monitoring in resource-limited regions: optional or necessary? Clin Infect Dis 2007; 44: 128–34.
911