• 1.

    WHO, 2017. WHO Global Tuberculosis Report 2017 [Internet]. Geneva, Switzerland: World Health Organization Press. Available at: http://www.who.int/tb/publications/global_report/en/. Accessed March 15, 2017.

    • Search Google Scholar
    • Export Citation
  • 2.

    Garfin C, Mantala M, Yadav R, Hanson CL, Osberg M, Hymoff A, Makayova J, 2017. Using patient pathway analysis to design patient-centered referral networks for diagnosis and treatment of tuberculosis: the case of the Philippines. J Infect Dis 216 (Suppl 7): S740S747.

    • Search Google Scholar
    • Export Citation
  • 3.

    Wells WA, Ge CF, Patel N, Oh T, Gardiner E, Kimerling ME, 2011. Size and usage patterns of private TB drug markets in the high burden countries. PLoS One 6: e18964.

    • Search Google Scholar
    • Export Citation
  • 4.

    Tupasi TE et al. 2000. Bacillary disease and health seeking behavior among Filipinos with symptoms of tuberculosis: implications for control. Int J Tuberc Lung Dis 4: 11261132.

    • Search Google Scholar
    • Export Citation
  • 5.

    Mantala MJ, 2003. Public–private mix DOTS in the Philippines. Tuberculosis (Edinb) 83: 173176.

  • 6.

    Auer C, Lagahid JY, Tanner M, Weiss MG, 2006. Diagnosis and management of tuberculosis by private practitioners in Manila, Philippines. Health Policy 77: 172181.

    • Search Google Scholar
    • Export Citation
  • 7.

    Lei X, Liu Q, Escobar E, Philogene J, Zhu H, Wang Y, Tang S, 2015. Public–private mix for tuberculosis care and control: a systematic review. Int J Infect Dis 34: 2032.

    • Search Google Scholar
    • Export Citation
  • 8.

    Wells WA, Uplekar M, Pai M, 2015. Achieving systemic and scalable private sector engagement in tuberculosis care and prevention in Asia. PLoS Med 12: e1001842.

    • Search Google Scholar
    • Export Citation
  • 9.

    Wells WA, Uplekar M, Dias HM, 2017. Guide to Develop a National Action Plan on Public-Private Mix for Tuberculosis Prevention and Care. Geneva, Switzerland: World Health Organization. Available at: chrome-extension://oemmndcbldboiebfnladdacbdfmadadm/https://www.who.int/tb/publications/2017/Final_Tool_PPM_action_plan.pdf?ua=1.

    • Search Google Scholar
    • Export Citation
  • 10.

    Uplekar M, 2003. Involving private health care providers in delivery of TB care: global strategy. Tuberculosis (Edinb) 83: 156164.

  • 11.

    Montagu D, Goodman C, 2016. Prohibit, constrain, encourage, or purchase: how should we engage with the private health-care sector? Lancet 388: 613621.

    • Search Google Scholar
    • Export Citation
  • 12.

    Surya A et al. 2017. Quality tuberculosis care in Indonesia: using patient pathway analysis to optimize public-private collaboration. J Infect Dis 216 (Suppl 7): S724S732.

    • Search Google Scholar
    • Export Citation
  • 13.

    Uplekar M, Atre S, Wells WA, Weil D, Lopez R, Migliori GB, Raviglione M, 2016. Mandatory tuberculosis case notification in high tuberculosis-incidence countries: policy and practice. Eur Respir J 48: 15711581.

    • Search Google Scholar
    • Export Citation
  • 14.

    Lal SS, Sahu S, Wares F, Lönnroth K, Chauhan LS, Uplekar M, 2011. Intensified scale-up of public-private mix: a systems approach to tuberculosis care and control in India. Int J Tuberc Lung Dis 15: 97104.

    • Search Google Scholar
    • Export Citation
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Perceptions of the Private Sector for Creating Effective Public–Private Partnerships against Tuberculosis in Metro Manila, Philippines

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  • 1 World Health Organization, Metro Manila, Philippines;
  • | 2 University of Washington, Seattle, Washington

This article’s goal is to assess the perspectives of private providers on current and future public–private engagement in Metro Manila, a city of 13 million using semistructured interviews with a convenience sample of 18 private physicians. Our study found that private providers perceived their clientele as loyal and their services as distinct from public services, with unique attractions of convenience and quality of service. They saw value in engaging with the public sector for knowledge exchange, access to public-sector commodities, and access to public sector assistance with public health tasks related to tuberculosis (TB). However, their proposed ways of engaging were more centered on the private sector role, in ways that are not currently being pursued by the public sector. It is of the utmost importance to recognize that private provider perspectives are essential to build effective engagement models and, thus, to reach all clients with quality TB care.

INTRODUCTION

Globally, an estimated 1.67 million people died of tuberculosis (TB) in 2016. In the Philippines, an estimated 573,000 people developed active TB of which 22,000 died.1 The 2016 National TB Prevalence Survey indicated that, despite increased efforts, TB prevalence has not decreased in the Philippines in the past 10 years.

The Philippines is home to a large private health sector. In 2016, approximately 36% of the TB patients, who sought care, initiated TB treatment in the private sector.2 This roughly translates to 125,000–175,000 TB patients being treated by the private sector each year, with studies of private sector TB drug sales suggesting this number may be even higher.3 However, diagnosis and treatment of TB in the private sector is expensive, of uncertain quality and poorly regulated.4,5 This can result in poorer treatment outcomes.6 In 2016, the private sector referred or notified (to the public sector) only about one-third of the TB patients that they are estimated to be treating.

Many projects in the Philippines and elsewhere have attempted to bridge this public–private divide, but challenges remain, in large part because public and private providers are known to have divergent perspectives.39 Previous work on this topic has found that public-private partnerships hold great potential in extending TB care to important populations. Yet programs’ success is contextual and often limited by finances, incentives, poor governance, limited communication between the public and private sectors, and mutual distrust.7,912 In the present study, we extended the scope of this work to the perspective of provider by collecting qualitative responses from private providers to outline their key perceptions, obstacles, and suggestions for building effective public–private partnerships for improved TB care in the Philippines.

METHODS

We conducted a series of in-depth interviews, with a convenience sample of 18 private physicians in the Metro Manila area that were selected based on a snowball approach and their availability. The interviewee pool consisted of six women and eight men; the age range for women was 40–60 years and the age range for men was 45–60 years. The interviews were one-on-one and face-to-face, using semistructured and open-ended questions from an interview guide and conducted in English. Written consent was obtained before the interviews and verbal consent obtained at the beginning of every interview. An independent service transcribed the audio recordings of the interviews. The lead author read all transcripts, first without coding and thereafter with coding. Inductive reasoning was used to detect regularities and patterns to elucidate thematic concerns and comments across interviews. As the interviews were structured around a few specific areas of private sector engagement, especially the facilitating and hindering factors, data saturation was reached after interviewing only 18 private physicians. The interviews first explored participants’ views on public–private dynamics and relationships in TB diagnosis and treatment. After this, the interview focused on how the private physicians envisioned improving these dynamics and relationships. Tangible and actionable implications were prioritized during data analysis. Square brackets have been used to clarify subjects of quotations and grammar-related ambiguities.

RESULTS

Factors that influence health seeking behavior of patients and private–public engagement.

The private physicians mentioned many facilitating factors and barriers that influence health seeking behavior of patients and private–public engagement.

Private physicians have a loyal patient population despite the costs.

Many participants stressed that patients seeking care in the private sector do so intentionally, despite higher consultation fees and drug costs. “Private sector patients are private sector patients,” said one private physician. Reasons cited for patients’ loyalty to the private sector included convenience, particularly in relation to patients’ work schedules; confidentiality; perceived higher quality than the public sector; and shorter wait times.

Patients return to the private sector, even after referral to government health-care facilities.

Most participants reported a high frequency of patients returning to their private practice after referral to government hospitals. One private physician of a standalone clinic said: “Whenever I present this option for referral to the public health facility to my patients, about 95% of them decide against it. They would rather pay out-of-pocket for their medications and be monitored by me.” The participants highlighted the differences in convenience as a reason for returning to the private sector: “Referred patients return to me for many reasons. They are not enrolled for treatment if they cannot comply with the schedule of the health center… or the schedule of the health center conflicts with their work.”

Many private physicians expressed hesitations about referring patients to government facilities because of the fear of losing their patients. One participant expressed a commonly addressed fear, saying that private providers are “afraid that they might lose their patients the moment they are referred to the public health centers.”

Private physicians see themselves as significantly different from public providers.

The participants outlined fundamental differences between the public and private sectors. They described these differences as resulting in complementary rather than competitive models of care. They described the private sector’s comparative advantages as greater convenience—regarding waiting times, scheduling, distance traveled, and required paperwork—and more personal care and confidentiality. The public sector’s comparative advantages, as they described, centered on monitoring public health trends, instituting wide policy changes and providing low-cost and no-cost diagnostics and drugs. A private physician with previous experience in the public sector stated that: “The private sector and the public sector have different strengths and patients. The public sector can initiate great changes. But the private sector has the doctors to carry them out.”

Private physicians report being out of touch with initiatives and protocols of the government.

The participants who were not officially enrolled in the government’s National Tuberculosis Program (NTP) described not having interacted with NTP officials for periods ranging from 6 months to 5 years. Although participants were sometimes aware of changes in the government’s diagnostic protocols, it was often outdated information and hence often not followed. One private physician said that she followed the “private sector’s clinical practice guidelines”; another reflected on this gap, saying: “Once we graduate from medical school or even residency training, there’s no mandate for regular training updates on these things. So it’s always physician-initiated or through medical representatives who come to you… If there’s a new policy, new methods of treatment, then you don’t really get to know about it once you graduate.”

Most private physicians described using outdated diagnostic criteria and tools, particularly an over-reliance on clinical diagnosis for TB rather than bacteriological tests. One participant said: “Over-reliance on clinical diagnosis is not within the protocol for TB management. But I still depend on clinical manifestations… The standard of diagnosis in private practice is the presence of symptoms and chest X-rays..” In response to questions about sputum microscopy, providers listed many reasons for not using it including a lack of sensitivity, distrust of bacteriological tests, and lack of emphasis on sputum microscopy in their medical education.

Private physicians find case notifications and access to diagnostics and drugs to be complicated.

When asked about case notifications to the NTP, most participants described the procedures as prohibitively cumbersome and, without incentives, difficult to justify in their practice. Most of them were unaware of the new TB Law (2016) that requires mandatory case notification by all TB care providers. They expressed discontent with both the processes of case notification and lack of incentives in the form of access to drugs and diagnostics from the public sector.

Particularly, most of them described great difficulties in accessing the government’s GeneXpert machines. One private physician remarked: “Referring our patients for GeneXpert is like a culture test now because the turnaround time is 1 month… because the processes are not patient-friendly. So why insist on referrals to public hospitals when there are many private hospitals in the area who are willing to receive GeneXpert?”

When asked if the government-procured GeneXpert machines could benefit the private sector, one participant responded: “…If you look at the facilities that received the free machines, they are all government’s. And they’re insisting that they will make it work when in fact, their manpower cannot absorb the workload. They’re only open Monday to Friday, 8 to 5. So how about those patients who are working and would like to access the services beyond office hours or on the weekends? Private hospitals can provide that convenience. But they are not open to giving Xpert machines to the private.. simply because they are afraid that once we start diagnosing TB using Xpert, we will no longer refer patients to them.”

Private physicians find certification processes of the government to be cumbersome.

The participants elaborated on their frustrations with the cumbersome certification processes of the government, without which they cannot access drugs and diagnostics from the public sector. One clinician at a private clinic said: “It used to be something like three requirements. It’s now 10… I would rather not be part of that. A lot of paperwork to fill up. You are not making it accessible for them [the private sector] to engage in the partnership. You are discouraging them from the partnership.”

Private physicians blame lack of communication with the public sector.

The participants cited lack of bilateral communication channels between private physicians and the NTP as an important factor in public–private partnership stagnation. One private physician noted that these barriers in communications are: “[It is] not just [about] the private reaching out. It’s also [about] the government accepting all. They still have this mentality that you [the private sector] are a problem. So, ‘you [the private sector] cooperate with us [the government]. If you don’t cooperate with us, then we will not mingle with you’.”

Private physicians worry about the non-sustainability of these initiatives.

The participants further noted that the public–private partnership initiatives are often time-bound projects. Without mechanisms to sustain them, they are bound for a natural decline in support and functioning. One participant questioned: “If the project would end, who would sustain it? And they will be [saying] – ‘Oh, I used to receive this much. But now it’s gone. So, what is it for me to continue?’”

Private physicians underline the importance of private–public engagement.

When asked about the prospects of public–private partnerships, most responses evoked a sense of disconnection between the public and private sector. However, when asked about the future, the participants underlined the importance of public and private partnerships. One private physician at a large private hospital embodied this, saying: “The private sector and the public sector have gone for too long working separately. We are all doctors and it is time to begin working together.”

Private physicians believe public–private partnerships should enhance the quality of both parties.

The participants stressed that public–private partnerships must be built on mutual respect. One private provider outlined the ideal public–private dynamic, saying: “In private-public partnerships, it would be good if we can share resources so that both can come together. This is because the government has resources, the private sector has resources. And then we come together in a program that mutually benefits the whole community.”

Ideas that may enhance private–public engagement.

The interview also included questions about the changes that private physicians thought would best enhance private sector participation in public–private partnerships. Themes from transcripts are summarized below.

Enhancing communication and collaboration with the private sector.

Suggestions of the participants centered around developing more equitable and frequent channels of communications, including regular forums. One internist underscored the importance of this, saying: “Private physicians must be kept informed on the latest research and policies. Any engagement will not work otherwise.”

Many participants stressed that the government or an interface agency should communicate by engaging existing networks of private physicians. One private physician said: “The best way to engage the private practitioners is through networking and linkages with key societies.”

Some participants suggested offering continuing medical education credits and establishing a “medical representative” model of orientation of private physicians.

Increasing case notifications from the private sector.

To improve case notifications from the private sector, the participants stressed the need to simplify and streamline the process of case notifications.

“The problem with reporting is that sometimes the questions are redundant… There’s too much paperwork that needs to be done.”

“Shortening it would really be good because every time I see a form that’s really long, I will [not make] an effort.”

Some physicians recommended use of a mobile application and report collection services to facilitate reporting.

Engaging public health nurses.

The participants underscored the need to support their clinics with public health personnel from the government. One private practitioner in an urban center noted that her staff struggled with meeting government requirements, saying: “You cannot mandate us [to participate] because we don’t have the personnel. By the Law, we need to follow. But how can we follow that? We cannot exhaust our personnel..”

The idea of government support for hiring dedicated public health nurses for large hospitals, or for nurses shared between multiple standalone clinics, was widespread among the interviewees. According to them, these nurses should assist them with TB case recording and notifications, specimen transportation, and contact investigations. One physician of a large private hospital said: “For the [partnership] program to really speed off, [we need] plantilla positions… because… I cannot do all those things at the same time. But if there will be personnel… who will be assigned to do that, the targets of the government will be [achieved]. I can assure you of that.”

Improving access to high-quality drugs and rapid diagnostics.

Most participants said that private sector patients should be able to access government-sponsored drugs and diagnostics within the private sector. One physician from a hospital suggested: “It would depend on the patient. If the patient would like free drugs, then give them the free drugs and charge handling fee. If they want branded drugs, then give the branded drugs. At the end of the day, you satisfy all types of patients.” One standalone private physician said, “If the NTP is going to provide drugs to the private sector, they have to be placed in private pharmacies.”

The participants voiced concerns about manpower and overhead costs for stocking, maintaining, and using government-supplied drugs and diagnostics. They underscored the necessity for the private sector to be able to charge their patients a “handling fee” or “service cost” for accessing these public sector drugs and diagnostics. An internist at an urban hospital suggested that: “The way to ensure NTP-supplied drugs and diagnostics aren’t sold at a price that may be too high would be by setting a ceiling on the service fee for the government-procured drugs and diagnostics.”

Private practitioners also expressed enthusiasm for participating in programs such as sputum transport networks. They said that would allow them to use high-quality government diagnostics such as rapid molecular tests. However, many of them also underlined the necessity to place government machines within the private sector. They described this as the most efficient method to ensure that the private sector patients can access affordable diagnostics.

One private physician summarized public–private partnerships with this statement: “I think it’s part of a Venn Diagram relationship. There are rules that are uniquely yours, meaning government’s, and ours and things that are shared. We only need to define them.”

DISCUSSION

This study provides a picture of private providers of TB services in Metro Manila—one that is clearly distinct from that of public providers, yet with potential for much greater cooperation between public and private entities. Of note, however, many of the private sector’s proposed solutions for that increased cooperation are more private—than public centric. These are not currently being pursued by the public sector adequately.

Private physicians are confident in their clientele’s loyalty and believe those clients have justifiable reasons for returning repeatedly to the personalized care in the private sector. This is not an allegiance that will be easily broken, based on public sector regulations or dictates. At the same time, private providers feel that the public sector has much to offer them. The private providers expressed interest in technical and programmatic updates from the public sector. They also sought greater access to public sector commodities and support from their personnel, particularly in regard to public health initiatives such as mandatory TB case notification.

The private sector provides care to a large proportion of the TB population. More than half of all TB patients consult a private physician before contacting the public sector and about one-third initiate care within this sector.2,4,5 Yet, private providers often use outdated diagnostic criteria and treatment regimens and most do not notify TB cases to the public sector.6 Public–private partnerships offer a cost-effective and comprehensive way to provide patient-centered, quality diagnostics; treatment; and public health initiatives that can increase the reach and effectiveness of TB initiatives and help patients wherever they seek care.

However, public–private partnerships’ success is highly contextual and public and private providers in the Philippines and elsewhere have been shown to have divergent perspectives.69 Yet, few studies have called upon private sector professionals to inform future initiatives. In our findings, private practitioners reported being out of touch with government initiatives. Many felt that government initiatives were neither suited for the realities of their practice nor benefitting their patients. Indeed, past studies call for continuous financial support and material input into the private sector to maintain public–private partnerships and simplified case notification mechanisms in the private sector for effective implementation of mandatory case notification.7,13

In our study, solutions were requested on private sector rather than public sector terms. Examples include convening meetings via professional associations (rather than at the times and locations preferred by public sector); introducing simplified systems more suited to private providers (for both TB notification and certification); the freedom to place public sector diagnostics and drugs—targeted for private patients—in private rather than public facilities; and the ability to charge limited service fees for administering access to those public sector commodities. Studies such as ours have the potential to re-orient the public–private conversation to a more equal, and more informed, footing.

Private practitioners underscored that the differences between government health services and private health services could be turned into an advantage. This would require both sectors to work toward acknowledging those differences and making them complementary to each other. The private sector has the advantages of greater convenience, confidentiality, and perceived quality of care. The public sector has a better public health understanding, access to novel and subsidized drugs and diagnostics, and organizational power. In the Philippines and elsewhere, public and private sectors need to respect each other’s uniqueness, communicate as equal partners, and share resources for a sustainable, mutually beneficial relationship.

A fragmented, out-of-touch private sector is a direct threat to broader initiatives under the End TB Strategy. Scaling up private sector engagement can be one of the most efficient usage of public resources for TB and must be considered in the scale-up of novel diagnostics.8,13,14 Creating public–private partnerships that incorporate and work with, rather than against, the perspectives of private providers, as outlined here, is an essential step in providing universal, patient-centered care.

REFERENCES

  • 1.

    WHO, 2017. WHO Global Tuberculosis Report 2017 [Internet]. Geneva, Switzerland: World Health Organization Press. Available at: http://www.who.int/tb/publications/global_report/en/. Accessed March 15, 2017.

    • Search Google Scholar
    • Export Citation
  • 2.

    Garfin C, Mantala M, Yadav R, Hanson CL, Osberg M, Hymoff A, Makayova J, 2017. Using patient pathway analysis to design patient-centered referral networks for diagnosis and treatment of tuberculosis: the case of the Philippines. J Infect Dis 216 (Suppl 7): S740S747.

    • Search Google Scholar
    • Export Citation
  • 3.

    Wells WA, Ge CF, Patel N, Oh T, Gardiner E, Kimerling ME, 2011. Size and usage patterns of private TB drug markets in the high burden countries. PLoS One 6: e18964.

    • Search Google Scholar
    • Export Citation
  • 4.

    Tupasi TE et al. 2000. Bacillary disease and health seeking behavior among Filipinos with symptoms of tuberculosis: implications for control. Int J Tuberc Lung Dis 4: 11261132.

    • Search Google Scholar
    • Export Citation
  • 5.

    Mantala MJ, 2003. Public–private mix DOTS in the Philippines. Tuberculosis (Edinb) 83: 173176.

  • 6.

    Auer C, Lagahid JY, Tanner M, Weiss MG, 2006. Diagnosis and management of tuberculosis by private practitioners in Manila, Philippines. Health Policy 77: 172181.

    • Search Google Scholar
    • Export Citation
  • 7.

    Lei X, Liu Q, Escobar E, Philogene J, Zhu H, Wang Y, Tang S, 2015. Public–private mix for tuberculosis care and control: a systematic review. Int J Infect Dis 34: 2032.

    • Search Google Scholar
    • Export Citation
  • 8.

    Wells WA, Uplekar M, Pai M, 2015. Achieving systemic and scalable private sector engagement in tuberculosis care and prevention in Asia. PLoS Med 12: e1001842.

    • Search Google Scholar
    • Export Citation
  • 9.

    Wells WA, Uplekar M, Dias HM, 2017. Guide to Develop a National Action Plan on Public-Private Mix for Tuberculosis Prevention and Care. Geneva, Switzerland: World Health Organization. Available at: chrome-extension://oemmndcbldboiebfnladdacbdfmadadm/https://www.who.int/tb/publications/2017/Final_Tool_PPM_action_plan.pdf?ua=1.

    • Search Google Scholar
    • Export Citation
  • 10.

    Uplekar M, 2003. Involving private health care providers in delivery of TB care: global strategy. Tuberculosis (Edinb) 83: 156164.

  • 11.

    Montagu D, Goodman C, 2016. Prohibit, constrain, encourage, or purchase: how should we engage with the private health-care sector? Lancet 388: 613621.

    • Search Google Scholar
    • Export Citation
  • 12.

    Surya A et al. 2017. Quality tuberculosis care in Indonesia: using patient pathway analysis to optimize public-private collaboration. J Infect Dis 216 (Suppl 7): S724S732.

    • Search Google Scholar
    • Export Citation
  • 13.

    Uplekar M, Atre S, Wells WA, Weil D, Lopez R, Migliori GB, Raviglione M, 2016. Mandatory tuberculosis case notification in high tuberculosis-incidence countries: policy and practice. Eur Respir J 48: 15711581.

    • Search Google Scholar
    • Export Citation
  • 14.

    Lal SS, Sahu S, Wares F, Lönnroth K, Chauhan LS, Uplekar M, 2011. Intensified scale-up of public-private mix: a systems approach to tuberculosis care and control in India. Int J Tuberc Lung Dis 15: 97104.

    • Search Google Scholar
    • Export Citation

Author Notes

Address correspondence to James Sherpa, University of Washington School of Medicine, Seattle, WA. E-mail: sherpajr@uw.edu

Disclaimer: The World Health Organization retains the copyright to this article and has granted the American Society of Tropical Medicine and Hygiene permission to publish it.

Authors' addresses: James Sherpa, World Health Organization, Metro Manila, Philippines, and University of Washington, Seattle, WA, E-mail: sherpajr@uw.edu. Rajendra-Prasad Yadav, World Health Organization, Metro Manila, Philippines, E-mail: yadavr@who.int.

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