Rethinking Public Private Mix (PPM) Performance in the Tuberculosis Program: How Is Care Seeking Impacting This Model in High TB Burden Countries?

In many high TB burden countries with enormous private-sector presence, up to 60-80% of the initial health-seeking behavior occurs in the private sector when people fall sick. Private-sector providers are also perceived to offer poorer-quality health service, and contribute to TB notification gaps and the spread of multidrug-resistant tuberculosis (MDR-TB). Recent efforts have focused on the expansion of TB services among private providers through public-private mix (PPM) initiatives. However, whether such efforts have matched the contribution of the private sector in TB notification, considering its enormous health-seeking volume, is debatable. Here, we argue that evaluating PPM program performance on the basis of the proportion of private-sector health seeking and level of undernotification is an imperfect approach due to differentials in tuberculosis risk profiles and access among patient populations seeking private care when compared with the public sector. We suggest a uniform definition of what constitutes PPM, and the standardization of PPM reporting tools across countries, including the ability to track patients who might initially seek care in the private sector but are ultimately publicly notified. PPM programs continue to gain prominence with rapid urbanization in major global cities. A universal health coverage framework as part of the PPM expansion mandate would go a long way to reduce the catastrophic cost of seeking TB care.

Automated summary

In many high TB burden countries, a large proportion of people seek healthcare in the private sector when they fall sick. The private-sector is often perceived to offer poorer-quality health services and contribute to gaps in TB notification and the spread of MDR-TB. Efforts have been made to expand TB services among private providers through public-private mix (PPM) initiatives. However, evaluating the performance of PPM programs solely based on the proportion of private-sector seeking healthcare and undernotification is not a perfect approach. It is suggested to establish a uniform definition of PPM and standardize reporting tools to track patients who initially seek care in the private sector but are ultimately notified publicly.