LETTERS

Invest in breaking the barriers of public–private collaboration for improved tuberculosis care

Knut Lönnroth¹; Mukund Uplekar

TB Strategy and Operations, Stop TB Department, World Health Organization, 1211 Geneva 27, Switzerland (email: lonnrothk@who.int)

Editor – Mahendradhata & Utarini rightly call for a an urgent move from feasibility studies of public–private collaboration in tuberculosis (TB) control to studies that analyse success factors as well as the cost and cost-effectiveness of such initiatives (1). WHO is currently coordinating a number of operational research initiatives that focus on these issues.

In the August 2004 issue of the Bulletin, we published a study on success factors for public–private collaboration in TB control (2). That analysis was based on project evaluations of four initiatives in three countries. We are continuously updating this analysis based on a rapidly growing body of data from more than 40 ongoing projects in 14 countries. A policy framework and tools to help implementation have been developed based on field experiences and operational research. Information about WHO's work on private sector involvement in TB control can be found on the web site: http://www.who.int/tb/dots/ppm.

Mahendradhata & Utarini highlight the fact that public–private collaboration for improved TB control takes place in a context of constrained resources and competing interests. Our analysis suggests that government investment is indeed crucial in order to ensure technical capacity-building in the private sector, managerial capacity-building in the public sector, improved supervision and quality control of private providers, and improved surveillance. Public funding is also needed in order to secure a supply of drugs and consumables free of charge to TB patients attending private clinics. While additional investments will be required, cost-effectiveness analysis of two collaborative projects in India has demonstrated that the amounts of such investments would be comparable, on a cost per successfully treated case basis, to those required by the public sector (3). From a societal perspective, a significant added value would be a substantial reduction in the financial burden on patients and, potentially, early detection and reduction in transmission of TB.

From documented experiences, what do we already know about why partnerships work? As expected, the determinants of success are precisely the factors that help to counter some of the well-known barriers to collaboration (4). First, a genuine commitment on the part of the public sector demonstrating that it is indeed interested in working with private providers; second, justifiable additional investments – human and financial – to help build the collaboration and contribute further to TB control; third, a proper situational analysis to develop a locally appropriate task-mix for public and private providers; fourth, orientation and training of both public and private providers to prepare them to work together; and finally, a built-in monitoring and evaluation system to continue to measure the benefits and to improve upon the collaboration (2, 5).

For Mahendradhata & Utarini's own project, if they intend to apply first what they mentioned first – the strategy of strengthening regulatory structures– then a word of caution is called for. Regulation of private providers is indeed crucial and must be dealt with. To begin with a heavy emphasis on "regulating" providers, however, could turn the project into a non-starter. Experience shows that in public–private partnership building, when to employ a strategy is as important as the strategy itself. This and similar potential stumbling blocks could be avoided if private providers are involved in the process right from the first step of planning an intervention and, more importantly, in a spirit of partnership.

Competing interests: The authors work with the Public–Private Mix for DOTS Initiative in the Stop TB Department at WHO.

References

1. Mahendradhata Y, Utarini A. Public–private partnership for tuberculosis control: the bill please? Bulletin of the World Health Organization 2005;83:78.

2. Lönnroth K, Uplekar M, Arora VK, Juvekar S, Lan NTN, Mvaniki D, et al. Public–private mix for improved TB control – what makes it work? Bulletin of the World Health Organization 2004;82:580-6.

3. Cost and cost-effectiveness of Public-Private Mix DOTS: evidence from two pilot projects in India. Geneva: World Health Organization; 2004. WHO document WHO/HTM/TB/2004.337.

4. Involving private practitioners in tuberculosis control: issues, interventions, and emerging policy framework. Geneva: World Health Organization; 2001. WHO document WHO/CDS/TB/2001.285.

5. Practical tools for involvement of private providers in TB control – A guide for NTP managers. Geneva: World Health Organization; 2003. WHO document WHO/CDS/TB/2003.325.

1 Correspondence should be sent to this author.