Exploring the Role of the Private Sector in Tuberculosis Detection and Management in Lima, Peru: A Mixed-Methods Patient Pathway Analysis

Christoph Wippel Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts;

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Sheyla Farroñay Socios En Salud Sucursal Peru, Lima, Peru;

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Hannah N. Gilbert Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts;

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Ana Karina Millones Socios En Salud Sucursal Peru, Lima, Peru;

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Diana Acosta Socios En Salud Sucursal Peru, Lima, Peru;

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Isabel Torres Socios En Salud Sucursal Peru, Lima, Peru;

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Judith Jimenez Socios En Salud Sucursal Peru, Lima, Peru;

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Valentina A. Alarcón Dirección de Prevención y Control de la Tuberculosis, Ministry of Health, Lima, Peru;

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Leonid Lecca Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts;
Socios En Salud Sucursal Peru, Lima, Peru;

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Courtney M. Yuen Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts;
Division of Global Health Equity, Brigham and Women’s Hospital, Boston, Massachusetts

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In Latin America, little is known about the involvement of private health-care providers in tuberculosis (TB) detection and management. We sought to gain a better understanding of current and potential roles of the private sector in delivering TB services in Peru. We conducted a mixed-methods study in North Lima, Peru. The quantitative component comprised a patient pathway analysis assessing the alignment of TB services with patient care-seeking behavior. The qualitative component comprised in-depth interviews with 18 private health-care providers and 5 key informants. We estimated that 77% of patients sought care initially at a facility with TB diagnostic capacity and 59% at a facility with TB treatment capacity. Among private facilities, 43% offered smear microscopy, 13% offered radiography, and none provided TB treatment. Among public-sector facilities, 100% offered smear microscopy, 26% offered radiography, and 99% provided TB treatment. Private providers believed they offered shorter wait times and a faster diagnosis, but they struggled with a lack of referral systems and communication with the public sector. Nonrecognition of private-sector tests by the public sector led to duplicate testing of referred patients. Although expressing willingness to collaborate with public-sector programs for diagnosis and referral, private providers had limited interest in treating TB. This study highlights the role of private providers in Peru as an entry point for TB care. Public–private collaboration is necessary to harness the potential of the private sector as an ally for early diagnosis.

Author Notes

Financial support: This work was supported by the NIH (DP2MD015102); the Master of Medical Sciences in Global Health Delivery program of Harvard Medical School Department of Global Health and Social Medicine, with financial contributions from Harvard University and the Ronda Stryker and William Johnston MMSc Fellowship in Global Health Delivery; and a Summer Research Travel Grant from the David Rockefeller Center for Latin American Studies.

Disclosures: This study received approval from the Socios En Salud Institutional Research Ethics Committee and was exempted by the Harvard Medical School Institutional Review Board. We obtained verbal consent from survey respondents and written consent from interview participants.

Authors’ contributions: C. M. Yuen, C. Wippel, H. N. Gilbert, and L. Lecca conceptualized the study. S. Farroñay, D. Acosta, and I. Torres collected the data with support from C. Wippel and V. Alarcón. A. K. Millones and J. Jimenez supervised study implementation. C. Wippel, H. N. Gilbert, and C. M. Yuen analyzed the data. L. Lecca, S. Farroñay, D. Acosta, and I. Torres helped to interpret the results. C. Wippel wrote the first draft of the manuscript and all other authors revised critically for content.

Authors’ addresses: Christoph Wippel and Hannah N. Gilbert, Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, E-mails: christoph_wippel@hms.harvard.edu and hannah_gilbert@hms.harvard.edu. Sheyla Farroñay, Ana Karina Millones, Diana Acosta, Isabel Torres, and Judith Jimenez, Socios En Salud Sucursal Peru, Lima, Peru, E-mails: sfarronay_ses@pih.org, amillones_ses@pih.org, dacosta_ses@pih.org, itorres_ses@pih.org, and jjimenez_ses@pih.org. Valentina A. Alarcón, Dirección de Prevención y Control de la Tuberculosis, Ministry of Health, Lima, Peru, E-mail: valarcon@minsa.gob.peru. Leonid Lecca, Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, and Socios En Salud Sucursal Peru, Lima, Peru, E-mail: llecca_ses@pih.org. Courtney M. Yuen, Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, and Division of Global Health Equity, Brigham and Women’s Hospital, Boston, MA, E-mail: courtney_yuen@hms.harvard.edu.

Address correspondence to Courtney M. Yuen, Brigham and Women’s Hospital, 75 Francis St., Boston, MA 02115. E-mail: courtney_yuen@hms.harvard.edu
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