03 Dec Bangladesh: icddr,b develops model to involve private sector in TB detection through specialized screening centers
[vc_row css_animation=”” row_type=”row” use_row_as_full_screen_section=”no” type=”full_width” angled_section=”no” text_align=”left” background_image_as_pattern=”without_pattern”][vc_column][vc_separator type=”normal” thickness=”2″ up=”20″ down=”20″][/vc_column][/vc_row][vc_row css_animation=”” row_type=”row” use_row_as_full_screen_section=”no” type=”full_width” angled_section=”no” text_align=”left” background_image_as_pattern=”without_pattern”][vc_column][vc_gallery type=”nivo” interval=”3″ images=”2405,2404″ img_size=”full”][vc_column_text]An innovative TB case finding approach
Bangladesh accounts for approximately 5% of the missing people with TB worldwide, most of which remain undiagnosed due to the lack of appropriate diagnostic and reporting mechanisms in the private health care sector. Icddr,b (formerly known as the International Centre for Diarrhoeal Disease Research, Bangladesh) developed a social enterprise model (SEM) in 2014 to detect and identify undiagnosed TB patients and strengthen TB control by involving the private sector in Bangladesh.
Under the SEM model, icddr,b established 3 TB screening centers (SCs) in Dhaka by combining external funding from Stop TB Partnership’s TB REACH Wave 3 and income generation from the centers. Each site is equipped with state-of-the-art digital X-ray systems, GeneXpert MTB/RIF systems and cartridges, set up with support from UNITAID. In 2017-2018, the model was expanded to 7 more centers – 4 in Dhaka, 2 in Chattogram and 1 in Sylhet – with support from TB REACH, the Global Fund and USAID/Challenge TB.
At these centers, the patients are offered low-cost, high-quality digital chest X-rays integrated with CAD4TB software, along with free Xpert MTB/RIF tests. The X-ray system software automatically scores every X-ray to indicate any abnormality that could be suggestive of TB, and people with presumptive TB are further examined via GeneXpert testing. People diagnosed with TB are counseled by health workers and referred for free treatment to the nearest directly observed treatment, short-course (DOTS) centers. All TB patients are also advised to consult their referring physician or any physician before initiating treatment in DOTS as per national TB guidelines.
A network of nearly 10’000 physicians from 1’221 public and private health care facilities was built to refer individuals for TB evaluation to icddr,b’s TB screening centers. To ensure more referrals, a total of 423 pharmacies near the SCs took part in orientation trainings, organized intermittently to sensitize pharmacists and drug sellers about TB management and referral options. The model was supported by a 360º communication strategy that used public advocacy regarding TB through billboards, leaflets, news reports and online advertisements.
Generating impact for a stronger TB response
An independent evaluation of the project in 2015 showed that approximately one-third of the new TB patients reported from Dhaka metropolitan area were diagnosed in these centers. At the city level, the 3 SCs in Dhaka detected 520 cases in total during the first 8 months of their operation, which represented 7% of total B+ TB notified in Dhaka Metropolitan Area in 2014 and this rate climbed to 34% by 2016. There was a substantial increase in the number of people with bacteriologically positive TB detected in the private sector.
From July 2014, the model led to ~100,000 referrals out of which over 80% came from private providers. Approximately 18’400 TB cases were detected: ~15’000 people with bacteriologically positive TB (nearly 30% of total positive cases from the three cities), 1’951 people with clinically diagnosed TB and 1’589 people with extra-pulmonary TB.
In addition, the project identified 554 people with drug-resistant TB and 166 people with TB via contact tracing who would have likely remained undetected otherwise. The newer DOTS centers established in January 2017 initiated treatment for 1’710 patients and enrolled 218 children on isoniazid preventive therapy (IPT) till date.
Challenges and opportunities encountered to date
It has been challenging to get patients to choose paid diagnostic services at the screening centers over free services offered by the public sector. Continued communication has helped to promote awareness of better-quality diagnosis and overcome this obstacle to some extent, although it has resulted in fewer case referrals to the SCs than expected over the progression period of the project. As a result, revenue growth has slowed down. Since the inception of the project, however, the social enterprise model has been able to generate revenue from subsidized chest X-rays to cover close to one-third of its operational costs.
In early 2017 icddr,b included a private sector DOTS program in the model, with support from the Global Fund. These DOTS services are integrated within the SEM and located inside the SCs, so the patients referred from the private sector, who prefer treatment under private physicians, are encouraged to seek treatment from there DOTS as well.
The Global Fund further supported existent SCs to expand their services to include extra-pulmonary TB detection, exploration of alternative channels of case finding and scale-up of non-formal health care providers engagement.
Through the SEM model, assistants of private physicians and drug sellers from pharmacies are now sensitized and engaged in the cascade of TB care to ensure more referrals.
Thanks to its impressive results in significantly increasing TB case notifications and having established a successful public-private provider model for TB care, SEM has been included in Bangladesh’s National Strategic Plan-PPM and nationwide scale-up of SEM is implemented in line with the PPM Operational Plan (2017-2020).[/vc_column_text][/vc_column][/vc_row]