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Keywords:

  • private practitioners;
  • TB control;
  • compliance;
  • Philippines

Summary

  1. Top of page
  2. Summary
  3. Introduction
  4. Methods
  5. Setting
  6. Study design and sampling method
  7. Survey instrument
  8. Telephone survey method
  9. Statistical analysis
  10. Results
  11. Telephone survey
  12. Characteristics of the private practitioners
  13. Clinical case diagnosis
  14. Management of TB patients
  15. Knowledge about TB control
  16. Attitudes towards the Filipino NTP
  17. TB patients and private practitioners
  18. Discussion
  19. Conclusions
  20. References

objective To investigate the knowledge, attitudes and perspectives of the Filipino private physicians (PPs) on tuberculosis (TB) control issues in the Philippines and their implications for future governmental public health policies.

design Cross-sectional telephone survey from June to October 2001.

participants In each of the 78 provinces of the Philippines we randomly selected 10 PPs from the provincial capital city, five PPs from an urban centre with more than 50 000 population, and one PP from 15 rural villages with <50 000 population, making a total of 30 PPs per province. These data were complemented with information from focus group discussions with health workers and policy makers working in TB control, and through personal interviews with PPs.

results We interviewed 1355 (57.9%) of 2340 PPs identified. TB was diagnosed mainly through X-ray (87.9%) and usually treated with inappropriate regimens of anti-TB drugs (89.3%). The PPs did not follow-up their TB patients, did not trace the defaulters (97.9%) and did not identify contacts (91.4%). Only 24.2% knew the National Tuberculosis Programme (NTP) policies in depth. They defined the NTP's weakest points as diagnosis through sputum microscopy (59.2%) and the management of smear negative patients (29.7%). Most PPs were willing to collaborate with the NTP (83.3%) provided they were paid (38.4%). More than a half (51.5%) objected to obligatory reporting of new TB cases. The PPs based their success in attracting TB patients to their offices on confidentiality (46.1%) and on the kind treatment and flexibility given (43.7%).

conclusions Diagnosis and treatment of TB patients is a daily issue for the PPs in the Philippines, although they did not follow usually the NTP guidelines. The majority of the PPs wished to collaborate with the NTP provided they were paid.


Introduction

  1. Top of page
  2. Summary
  3. Introduction
  4. Methods
  5. Setting
  6. Study design and sampling method
  7. Survey instrument
  8. Telephone survey method
  9. Statistical analysis
  10. Results
  11. Telephone survey
  12. Characteristics of the private practitioners
  13. Clinical case diagnosis
  14. Management of TB patients
  15. Knowledge about TB control
  16. Attitudes towards the Filipino NTP
  17. TB patients and private practitioners
  18. Discussion
  19. Conclusions
  20. References

Global concern about tuberculosis (TB) control has risen in the past decade as a major international health issue. Governments and public administrations of most countries, particularly those with a high TB burden, have developed new TB programmes in order to address the increasing incidence of this disease. The political responsibility and commitment of the governments are key points within the DOTS (directly observed treatment, short course) strategy, the plan currently backed by the World Health Organization (WHO) to control TB.

However, high burden TB countries are also low- or middle-income nations where government-run public health services are frequently underfunded and facing several obstacles to achieve adequate outcomes. In this framework, a broad variety of actions to improve health system performance have been launched during the last decade under the so-called Health Sector Reform. This new approach contemplates the growing weight of the private sector as a health service provider and the requirement of co-operation with the public health sector as shows Weil (2000).

In the 22 countries with the highest prevalence of TB, a mean of 62.6% of the total health expenditure is spent on private health providers, being a mean of 58.9% in out-of-pocket disbursement as demonstrated (Uplekar et al. 2001). This circumstance has become patent in the case of health services related to TB overall in Asian countries. Studies of the health-seeking behaviour of TB patients in India (Uplekar et al. 1998), Pakistan (Khan et al. 2000), Vietnam (Lönnroth et al. 2001a) and The Philippines (Tupasi et al. 2000) showed that up to more than half of these patients had consulted a private physician (PP) in some point. Moreover, use of private health care providers is not clearly correlated with socio-economic status, and extends to all social strata.

The Philippines is one of the few countries with high TB burden that has developed a private–public mix project to tackle TB that includes a DOTS-plus model to treat multidrug resistant (MDR) TB cases. Taking into account the importance of the public–private collaboration in TB care to achieve the control of the disease in The Philippines, we designed this study to examine the knowledge, attitudes, and perspectives of the Filipino PPs about TB, and their implications in the making of future governmental public health policies.

Setting

  1. Top of page
  2. Summary
  3. Introduction
  4. Methods
  5. Setting
  6. Study design and sampling method
  7. Survey instrument
  8. Telephone survey method
  9. Statistical analysis
  10. Results
  11. Telephone survey
  12. Characteristics of the private practitioners
  13. Clinical case diagnosis
  14. Management of TB patients
  15. Knowledge about TB control
  16. Attitudes towards the Filipino NTP
  17. TB patients and private practitioners
  18. Discussion
  19. Conclusions
  20. References

The Philippines has a population of 77 million, is geographically scattered over 7107 islands, and bears the world's seventh highest TB burden. TB is the fifth most frequent cause of morbidity and mortality in the whole nation (National Statistical Coordination Board 2001a).

In the 1990s the Filipino Department of Health (DoH) launched a new National Tuberculosis Programme (NTP) that included the objectives contemplated in the DOTS strategy as its main goals. This programme guarantees free TB diagnosis and supervised treatment for every adult with active TB. These activities take place mainly in a well-structured network of governmental urban and rural health units scattered across the country (more than 2400 units in total). Non-specific measures were designed within the NTP to target those TB cases identified by the private health sector. In the past, low quality health services and problems in the procurement and distribution of free anti-TB drugs provided by the public sector had discredited the TB programme among the general population, who frequently resort to private health services instead (Tupasi et al. 2000).

The role of the private health sector in the Filipino context is remarkable: 63% of hospitals and 47.7% of total bed capacity are in private hands. There are no accurate data on the whole private health business, but small private clinics are ubiquitous. Health expenditures are mainly from private sources (57.2%): out-of-pocket funds (46.2%) followed by governmental funds (37.9%) and social insurance pools (4.9%). Meanwhile, the share of governmental public health expenditure of Gross National Product has remained below 3.5% in the last decade (National Statistical Coordination Board 2001b), and is likely to maintain this level in the immediate future – far from the 5% recommended by WHO. Contrary to the public health sector, private health services are heterogeneous and co-ordinated neither among themselves nor with governmental services in matters related to public health.

Study design and sampling method

  1. Top of page
  2. Summary
  3. Introduction
  4. Methods
  5. Setting
  6. Study design and sampling method
  7. Survey instrument
  8. Telephone survey method
  9. Statistical analysis
  10. Results
  11. Telephone survey
  12. Characteristics of the private practitioners
  13. Clinical case diagnosis
  14. Management of TB patients
  15. Knowledge about TB control
  16. Attitudes towards the Filipino NTP
  17. TB patients and private practitioners
  18. Discussion
  19. Conclusions
  20. References

A cross-sectional survey from June to October 2001 was conducted. In order to target the whole nation, a stratified purposeful sampling scheme taking into account each of the 78 provinces into which The Philippines is administratively divided, was developed. The capital of each province was included in the study. In a further selection, another large urban area (more than 50 000 population) was randomly chosen. As representative of rural zones, 15 villages per province with economies based on agrarian activities and with populations below 50 000 were randomly selected, using public data from 2000 (National Statistical Coordination Board 2001b). In each provincial capital, we identified 10 PPs, in each large city, five PPs, and in each village, one PP, resulting in a sample of 2340.

We found the PPs through local telephonic business directories and regional Yellow Pages. Cost-effectiveness and reliability of sampling PPs through registers of medical associations or governmental provincial health departments were considered but dropped, as they presented bureaucratic obstacles when asked to target the PPs. Identification by street searching or face-to-face interviews would have required human and financial resources that were not available.

Survey instrument

  1. Top of page
  2. Summary
  3. Introduction
  4. Methods
  5. Setting
  6. Study design and sampling method
  7. Survey instrument
  8. Telephone survey method
  9. Statistical analysis
  10. Results
  11. Telephone survey
  12. Characteristics of the private practitioners
  13. Clinical case diagnosis
  14. Management of TB patients
  15. Knowledge about TB control
  16. Attitudes towards the Filipino NTP
  17. TB patients and private practitioners
  18. Discussion
  19. Conclusions
  20. References

A questionnaire was developed after consultation with the NTP managers, epidemiologists, and public health experts on TB control. The questionnaire explored the relationship between TB as a public health problem and the role of the PPs and consisted mainly of closed yes/no and multiple-choice questions. Proposed answers were obtained from previous qualitative research carried out to develop a public–private mix approach for the control of TB (unpublished data). Most of the questions had an open answer to be given if the interviewee did not find the given options appropriate.

We collected demographic and geographical data (Luzon, Visayas or Mindanao administrative zone), information on the PPs' professional qualifications (general practitioner/family medicine, chest physician and internal medicine/infectious diseases), place of work (big hospital, small hospital, policlinic and private personal clinic), and whether they worked in both private and public health sectors. Paediatricians were excluded as the NTP in the Philippines is focused on adult patients. A big hospital was defined as a medical centre with 80 or more beds, a small hospital as one with <80 bed capacity. Polyclinic was defined as a medical centre where several doctors of the same or different specialities attended outpatients, and personal private clinic as a space where a doctor practised medicine as a liberal art.

The following medical case was proposed to the PPs as a quiz diagnosis: ‘a 32-year-old Filipino male with no previous history of personal or familiar illness, presents with fever, chronic cough, haemoptysis and weight loss of more than 2 weeks’ duration. What is the most probable diagnosis among the following: respiratory infection, pneumonia, lung cancer, TB, or other diseases (specify which one)'.

We investigated the management of TB patients by the PPs: how many new TB patients they saw per month and how they diagnosed TB, treatment options, study of the patient's contacts, tracing of defaulters, selling anti-TB drugs over the counter, and diagnostic tools available for TB in their work place. We observed how PPs monitored the clinical history of their TB patients and the possibility of getting valuable data for epidemiological statistics.

We determined how much knowledge of TB control issues there was within the Filipino NTP. Knowledge of the NTP was considered in-depth if the PP was able to classify correctly two TB cases among the three current stages (I, II or III), could treat them with the proper pattern of anti-TB drugs and follow them up with the appropriate schedule of sputum examinations. PPs were asked if they knew the five components of the DOTS strategy; if three or more of these components were recognized the knowledge was judged adequate. Interviewed doctors had the opportunity to consult national guidelines on TB if they had them available. We wanted to check the awareness of state-of-the-art knowledge on TB control among PPs. If they did not remember the proper treatment or follow-up schedule of TB patients at the moment of the interview but if they could consult these guidelines at their workplace, we considered the practice correct.

We also explored the attitudes of PPs towards future collaboration with the NTP activities: obligatory case report of TB patients, willingness to collaborate with the NTP, conditions required for the private–public collaboration, and what they considered weaknesses of the NTP. Lastly, PPs were asked whether they thought that TB patients preferred visiting a PP rather than a physician of the public health sector, and if so, why.

Telephone survey method

  1. Top of page
  2. Summary
  3. Introduction
  4. Methods
  5. Setting
  6. Study design and sampling method
  7. Survey instrument
  8. Telephone survey method
  9. Statistical analysis
  10. Results
  11. Telephone survey
  12. Characteristics of the private practitioners
  13. Clinical case diagnosis
  14. Management of TB patients
  15. Knowledge about TB control
  16. Attitudes towards the Filipino NTP
  17. TB patients and private practitioners
  18. Discussion
  19. Conclusions
  20. References

After identification of physicians through local directories, telephone numbers of private residences or medical offices were used. If the physician acknowledged private medical practice and agreed to answer, the interview went on. The physicians were informed that the questionnaire was related to public health matters in the private health sector, and confidentiality was assured. They were not informed that the questionnaire was focused on TB control to avoid bias in the answer of the medical case quiz. If they did not answer all questions, the questionnaire was considered as not valid. When telephone calls were not answered at the first try, three more attempts on different days were made.

Pilot testing was conducted over a 3-week period among the PPs of Metro Manila and the questionnaire was modified accordingly. Telephonic interviews lasted for about 15–25 min and were conducted in English or Tagalog (the official language of the Philippines) by five previously trained medical students. The results were re-tested after completion of the interview by the same interviewer to verify the answers.

Statistical analysis

  1. Top of page
  2. Summary
  3. Introduction
  4. Methods
  5. Setting
  6. Study design and sampling method
  7. Survey instrument
  8. Telephone survey method
  9. Statistical analysis
  10. Results
  11. Telephone survey
  12. Characteristics of the private practitioners
  13. Clinical case diagnosis
  14. Management of TB patients
  15. Knowledge about TB control
  16. Attitudes towards the Filipino NTP
  17. TB patients and private practitioners
  18. Discussion
  19. Conclusions
  20. References

Data obtained from the PPs interviewed were stratified by sex, age (25–30, 31–40, 41–50 and >50 years), setting of medical practice (urban or rural area), geographical situation (Luzon, Visayas and Mindanao), medical background (general medicine/family medicine, chest physician or internal medicine/infectious diseases), place of work (big hospital, small hospital, polyclinic or private personal clinic), and working or not at in both private and public health sectors. Continuous variables were defined as mean ± SD and discontinuous variables as percentage (%). Data was compared among stratification groups in bivariate analysis using t-test and chi-square test. Statistical significance was set at P < 0.05. Those variables that showed statistical significance in bivariate analysis were introduced in a multivariate analysis with standard logistic regression, in order to obtain the independent variables through adjusted odds ratio (OR) and 95% confidence intervals (95% CI). Analyses were performed using Epi-Info 6 and SPSS 10.0 (SPSS, Chicago, IL, USA).

Telephone survey

  1. Top of page
  2. Summary
  3. Introduction
  4. Methods
  5. Setting
  6. Study design and sampling method
  7. Survey instrument
  8. Telephone survey method
  9. Statistical analysis
  10. Results
  11. Telephone survey
  12. Characteristics of the private practitioners
  13. Clinical case diagnosis
  14. Management of TB patients
  15. Knowledge about TB control
  16. Attitudes towards the Filipino NTP
  17. TB patients and private practitioners
  18. Discussion
  19. Conclusions
  20. References

A total of 2340 telephone interviews were attempted and 1355 physicians (57.9%) who maintained medical practices in the private sector completed the interview. Of the remaining 985 physicians, 28.1% (n = 2340) did not want to participate in this study or stopped short the interview, 9.4% could not be reached by telephone, and 4.5% did not work in the private sector. The sample of the PPs that did not participate in this study cannot be compared with the PPs studied because of lack of public data. We only knew the name of the PPs, their corporation name, address, and telephonic number. The complete personal and professional data were collected through our questions. A database with this kind of information about PPs in the Philippines does not exist.

Characteristics of the private practitioners

  1. Top of page
  2. Summary
  3. Introduction
  4. Methods
  5. Setting
  6. Study design and sampling method
  7. Survey instrument
  8. Telephone survey method
  9. Statistical analysis
  10. Results
  11. Telephone survey
  12. Characteristics of the private practitioners
  13. Clinical case diagnosis
  14. Management of TB patients
  15. Knowledge about TB control
  16. Attitudes towards the Filipino NTP
  17. TB patients and private practitioners
  18. Discussion
  19. Conclusions
  20. References

Most PPs interviewed in this study were males, 46.7 ± 13.9 years old, general practitioners or family medicine specialists, who worked in their own private clinic located in an urban area of Luzon Island. The stratified complete data are shown in Table 1.

Table 1.  Characteristics of the private practitioners interviewed (n = 1355)
CharacteristicNumber (%)
  1. GP, General Practitioners; IM, Internal Medicine; ID, Infectious Diseases.

Sex
 Male987 (72.8)
 Female386 (27.2)
Age (years)
 25–3059 (4.3)
 21–40332 (24.5)
 41–50539 (39.8)
 >50425 (31.4)
Setting
 Urban731 (53.9)
 Rural624 (46.1)
Speciality
 GP/family medicine513 (37.8)
 Chest physician493 (36.4)
 IM/ID349 (25.8)
Geographical situation
 Luzon711 (52.5)
 Visayas377 (27.8)
 Mindanao267 (19.7)
Institution
 Big hospital91 (6.7)
 Small hospital197 (14.6)
 Polyclinic274 (20.2)
 Personal clinic793 (58.5)
Working in both sectors 
 Yes473 (34.9)
 No882 (65.1)

Clinical case diagnosis

  1. Top of page
  2. Summary
  3. Introduction
  4. Methods
  5. Setting
  6. Study design and sampling method
  7. Survey instrument
  8. Telephone survey method
  9. Statistical analysis
  10. Results
  11. Telephone survey
  12. Characteristics of the private practitioners
  13. Clinical case diagnosis
  14. Management of TB patients
  15. Knowledge about TB control
  16. Attitudes towards the Filipino NTP
  17. TB patients and private practitioners
  18. Discussion
  19. Conclusions
  20. References

Most of the PPs suspected a diagnosis of respiratory infection (45.8%, n = 1355), followed by TB (29.7%), pneumonia (14.5%), lung cancer (8.0%) and other diseases (2.0%). Multivariate analysis showed that the diagnosis of TB was three times more likely from specialized physicians (chest, internal medicine and infectious diseases) than from general practitioners or family physicians (OR 3.55, 95% CI: 2.69–4.68, P < 0.0001). Other variables that showed significant correlation with the diagnosis of TB were working in the public and private health sectors at the same time (OR 2.81, 95% CI: 2.19–3.62, P < 0.001) and working in a hospital (OR 2.64, 95% CI: 2.0–3.49, P < 0.001).

Management of TB patients

  1. Top of page
  2. Summary
  3. Introduction
  4. Methods
  5. Setting
  6. Study design and sampling method
  7. Survey instrument
  8. Telephone survey method
  9. Statistical analysis
  10. Results
  11. Telephone survey
  12. Characteristics of the private practitioners
  13. Clinical case diagnosis
  14. Management of TB patients
  15. Knowledge about TB control
  16. Attitudes towards the Filipino NTP
  17. TB patients and private practitioners
  18. Discussion
  19. Conclusions
  20. References

Most of the PPs diagnosed five to 10 new cases per month (53.5%), more than a third (37.2%) diagnosed less than five new TB patients per month, and almost one-tenth diagnosed more than 10 cases per month (9.3%). TB diagnoses were mainly based on X-ray findings (87.9%), and to a lesser extent, on symptoms given by the patient (6.1%) or physical examination (3.1%). Only 2.9% of the PPs manned sputum microscopy examination as a key tool for TB diagnosis in their patients. However, the only tools they had available for TB diagnosis were physical assessment (61.9%, n = 1355), followed by X-ray (22.3%), and microscopy sputum examination (17.4%).

Commonly PPs intended to treat their TB patients throughout the course of the disease (87.8%); referrals to colleagues or the governmental health sector (12.3%) were relatively rare. Inquiring about the patient's close contacts to search for new cases was rare (8.6%) and tracing of defaulters exceptional (2.1%). More than half of PPs prescribed anti-TB drugs sold over-the-counter at their practices (54.6%). Only 20.4% kept a standardized clinical history of their TB patients with valuable data for epidemiological statistics. The PPs described 64 patterns of standard treatments for TB, among them monotherapy (8.7%), a combination of two anti-TB drugs (30.3%), triple therapy (41.9%), and quadruple therapy (19.1%). Only 10.7% of the PPs correctly described the current standard treatment of the Filipino NTP. Selection of monotherapy regimens was more likely to happen among general practitioners than among the rest of the PPs (OR 3.62, 95% CI: 2.89–4.12, P < 0.001).

Knowledge about TB control

  1. Top of page
  2. Summary
  3. Introduction
  4. Methods
  5. Setting
  6. Study design and sampling method
  7. Survey instrument
  8. Telephone survey method
  9. Statistical analysis
  10. Results
  11. Telephone survey
  12. Characteristics of the private practitioners
  13. Clinical case diagnosis
  14. Management of TB patients
  15. Knowledge about TB control
  16. Attitudes towards the Filipino NTP
  17. TB patients and private practitioners
  18. Discussion
  19. Conclusions
  20. References

Less than one-quarter (24.2%) of the PPs was well-acquainted with the Filipino NTP guidelines, meaning that they were aware of the classification of TB cases, the proper treatment in each category, and the follow-up schedule of sputum examinations. About 26.7% of the PPs knew three or more of the DOTS strategy's five components. Only 6.8% of the PPs had trained in public health issues during their college years; a scarce 5.2% had upgraded their information on TB control. Lastly, 6.9% of the PPs informed their TB patients that they could be treated for free in the public health sector. In-depth knowledge of the NTP was the only variable significantly correlated with the PPs that worked in both the public and private health sectors (OR 3.61, 95% CI: 2.81–4.65, P < 0.0001 and OR 2.72, 95% IC: 2.21–3.79, P < 0.0001).

Attitudes towards the Filipino NTP

  1. Top of page
  2. Summary
  3. Introduction
  4. Methods
  5. Setting
  6. Study design and sampling method
  7. Survey instrument
  8. Telephone survey method
  9. Statistical analysis
  10. Results
  11. Telephone survey
  12. Characteristics of the private practitioners
  13. Clinical case diagnosis
  14. Management of TB patients
  15. Knowledge about TB control
  16. Attitudes towards the Filipino NTP
  17. TB patients and private practitioners
  18. Discussion
  19. Conclusions
  20. References

More than three quarters (76.3%) of the PPs did not agree with the current Filipino national policy on TB control. They found that the weakest point of this policy was the diagnosis based on sputum microscopy examination (52.9%), followed by the management of TB patients with smear negative sputum examination (19.5%), anti-TB drug issues (10.2%), treatment options (9.3%), and other topics (1.8%). Only 6.3% of the PPs found nothing wrong in the policy on TB control.

Half of the PPs (51.5%, n = 1355) did not agree with the obligatory case reporting of new TB cases to the DoH. Regardless of this fact, 83.3% of the physicians expressed their willingness to collaborate with the NTP; 90.3%, n = 1129 of them wanted to be rewarded for this. 77.3% of the PPs mentioned monetary compensation, 18.2% refreshment courses on TB control, and 4.5% other alternatives. None of the variables that described the characteristics of the PPs showed a significant correlation with these attitudes.

TB patients and private practitioners

  1. Top of page
  2. Summary
  3. Introduction
  4. Methods
  5. Setting
  6. Study design and sampling method
  7. Survey instrument
  8. Telephone survey method
  9. Statistical analysis
  10. Results
  11. Telephone survey
  12. Characteristics of the private practitioners
  13. Clinical case diagnosis
  14. Management of TB patients
  15. Knowledge about TB control
  16. Attitudes towards the Filipino NTP
  17. TB patients and private practitioners
  18. Discussion
  19. Conclusions
  20. References

The PPs thought that TB patients could prefer the private health sector because of confidentiality issues (46.1%), followed by kind treatment and flexibility in the provision of health care (43.7%), short waiting times (7.1%), and other matters (3.1%).

Discussion

  1. Top of page
  2. Summary
  3. Introduction
  4. Methods
  5. Setting
  6. Study design and sampling method
  7. Survey instrument
  8. Telephone survey method
  9. Statistical analysis
  10. Results
  11. Telephone survey
  12. Characteristics of the private practitioners
  13. Clinical case diagnosis
  14. Management of TB patients
  15. Knowledge about TB control
  16. Attitudes towards the Filipino NTP
  17. TB patients and private practitioners
  18. Discussion
  19. Conclusions
  20. References

The private health sector will be a key health provider for the Filipinos in the next years. The changes of health policies in developing countries such as the Philippines are having an important impact on vertical public health programmes as TB control, incorporating new stakeholders like those coming from the private health sector. Our findings showed that a big portion of a main public health issue is being managed by the private health sector. TB diagnosis and treatment were common for the PPs interviewed in the study, as also reflected in other analyses conducted in high TB burden countries (Lönnroth et al. 2001b; Pathania 2001). TB patients in developing countries are not necessarily poor and dependent on free or subsidized public health services, but the public health sector is underfunded and offers a low quality service in the shanty towns of Metro Manila and other big urban areas, where more than 40% of the total population live, and in rural areas where public health centres strongly depend on funding from municipal budgets after the devolution of the health service responsibilities from national level to local governmental units.

Despite being a major cause of morbidity and mortality in the country, TB was not the first diagnostic option for the PPs interviewed about a clinical case that was highly compatible with active TB. Specialists were more competent to diagnose TB than general practitioners. These findings highlight the necessity to strengthen the education on TB control among the general practitioners that might be the first medical contact of the TB patient.

Evaluation of the management of TB patients demonstrated high similarity with the behaviour of PPs in other developing countries (WHO 2001). Diagnosis through X-ray findings, not identifying the contacts, not tracing defaulters and incorrect treatment were the main outcomes. The implications for TB control are clear: X-ray diagnosis is incapable to identify at early stages those smear positive cases which perpetuate the transmission of the disease in the community. On the other hand, erroneous diagnosis of TB through X-ray findings unnecessarily exposes certain subjects to anti-TB drugs, the social stigma of the disease, and the economic burden of having to buy anti-TB drugs. Not studying contacts complicates the identification of recently infected cases, or even of the source of infection. Incorrect and incomplete treatments are the main causes of resistant species to conventional anti-TB drugs. Therefore addressing the mismanagement of TB patients in the private sector is crucial for effective TB control in the country, especially if the governmental health services are not attractive for the general population.

Registry and completion of clinical records of TB patients were usually inadequate to obtain data for epidemiological purposes. Although a considerable number of TB patients worldwide are managed by PPs, it is remarkable that the institutions that survey the TB epidemic in developing countries (from international to national levels) have not yet considered collecting data from the private health sector, which may lead to serious underestimates of the TB epidemic in our context. Inclusion of standardized data from the private health sector is needed to survey more accurately case detection and treatment outcome rates, as well as drug-resistant cases.

The PPs commonly sold anti-TB drugs over-the-counter. These drugs are not tested and regulated as are those sold in the public sector, and even come packaged in non-standard doses that complicate dose adjustment to the weight of the patient. The cost of these drugs can be a significant barrier for the most underprivileged TB patients who could be forced to stop their treatments. Proper prescription and management of anti-TB drugs in the private sector has to be enforced by the government to avoid the increasing number of drug-resistant cases because of medical malpractice and lack of treatment compliance. Anti-TB drugs must be considered a ‘public good’ for the community, and therefore management in public settings with the appropriate quality control measures and free of charges, guarantee their access to all the citizens.

New approaches to link the private and public sectors in the control of TB must be developed taking into consideration that despite socio-economical status, many people prefer being treated by PPs rather than by physicians working in a governmental health centre. In the current circumstances, a future approach could be that the PPs followed up their TB patients using the NTP guidelines, but that patients receive anti-TB drugs free of charge in the health centre. These services should be provided free of charge and covered under the social security network as the local Philhealth scheme. This private–public collaboration could improve the treatment compliance of TB patients and guarantee the quality of the drugs taken in the private health sector. Experiences such as those of the DOTS-plus Project among private and public stakeholders, which is based on free diagnosis and treatment of MDR TB cases, could be a model for future collaborations. However, the appropriateness and sustainability of this model is arguable in such a heterogeneous field, as it is the private health sector conditioned by the economic profit.

The traditional ostracism of PPs on TB control issues might explain their disagreement with the NTP and their unawareness of the current guidelines. Therefore, the inclusion of the PPs in the forums that decide the policy on TB control could increase the feasibility of a private–public partnership. Notably, PPs named diagnosis by sputum microscopy and management of smear negative patients as the weakest points of the NTP, possibly because of the past medical education that taught diagnosis of TB mainly based on X-ray findings instead of using sputum microscopy. However, logistic problems to access laboratories with microscopy facilities and corporate interests among the PPs and the private radiologists might also explain these practices. Likewise, better use of the current public and private resources regarding microscopy diagnosis could produce a high impact in the case detection rate of TB taking into account that most of the PPs interviewed in this study did not have any diagnostic tool for TB other than physical assessment.

Lack of training of the PPs in public health can hinder their understanding of the implications of TB for community health. Medical schools, especially in the high TB burden countries, need to address this. Physicians who work in both health sectors can be successful stakeholders in the implementation of TB control measures in the private sector and in the elaboration of private–public mix guidelines. Nevertheless, private–public collaborations might be designed taking into account every specific situation. The heterogeneity of the private health sector (in opposition to the homogeneity of the public health sector) might explain why developing a unique consensus guideline might not be appropriate for in all circumstances.

Collaboration of the PPs in TB control was by an expectation of reward. TB patients, as any others, are a source of income for PPs. Thus more than a third worked in both sectors mainly to increase their income through their private services. Economic support from the NTP to the PPs is considered unfeasible, since the governmental NTP already has an important funding gap. Medical fee charges in the private health sector used to be a serious barrier for low-income TB patients to seek medical care; as well as the high cost of anti-TB drugs in the open market. Therefore, the provision of TB health services by the private sector, obviously profit-orientated, could jeopardize the sense of equity that must guide a public health programme, especially in control of diseases strongly related to poverty. By the same token, the low emphasis given so far by private–public mix projects to the referral system of suspected TB patients from the private to the public sector is remarkable. The most cost-effective system is to increase the case detection rate, to treat and to diagnose for free, and to follow-up properly the TB patients in the well-structured public health network where all the health professionals have been trained in TB control. Thus, the main aim of the private health sector should be to improve their skills of TB diagnosis and refer patients for free diagnosis and treatment to the public sector. Other proposals of private–public projects would have to demonstrate if they can be competitive in terms of equity, quality and cost-effectiveness with the public sector.

The PPs considered as keys for their success with TB patients mainly confidentiality, kind treatment, and the flexibility in the delivery of their health services. This could be interpreted as a reflection of the weakest points in the public health sector, and might explain the shift to the private health sector on behalf of the TB patients. However, both health sectors have successful achievements to share: the private health sector has been capable to attract TB patients from all socio-economic strata by paying attention to the individual priorities and necessities of the subjects, while the public health sector has procured the implementation of international consensus guidelines on TB control free of charge for the all the Filipinos.

In the light of the findings of this study, we plead for a strong referral system of suspected TB patients from the private health sector to the public sector, increasing the conscience of the importance of the public health among the private sector stakeholders and calling for their responsibilities within society. Continuous operational research in both sectors must aid in defining health policy on TB control.

Conclusions

  1. Top of page
  2. Summary
  3. Introduction
  4. Methods
  5. Setting
  6. Study design and sampling method
  7. Survey instrument
  8. Telephone survey method
  9. Statistical analysis
  10. Results
  11. Telephone survey
  12. Characteristics of the private practitioners
  13. Clinical case diagnosis
  14. Management of TB patients
  15. Knowledge about TB control
  16. Attitudes towards the Filipino NTP
  17. TB patients and private practitioners
  18. Discussion
  19. Conclusions
  20. References

Diagnosis and treatment of TB patients was common for the PPs in the Philippines. They based their diagnosis mainly on X-ray findings, did not follow-up on TB patients or their contacts, usually treated them with an incorrect anti-TB drug regimen, failed to maintain standardized records of TB patients and objected to obligatory reporting of new cases. PPs disagreed with the NTP policy despite not knowing the programme in depth. Most PPs were willing to collaborate with the NTP for pay.

References

  1. Top of page
  2. Summary
  3. Introduction
  4. Methods
  5. Setting
  6. Study design and sampling method
  7. Survey instrument
  8. Telephone survey method
  9. Statistical analysis
  10. Results
  11. Telephone survey
  12. Characteristics of the private practitioners
  13. Clinical case diagnosis
  14. Management of TB patients
  15. Knowledge about TB control
  16. Attitudes towards the Filipino NTP
  17. TB patients and private practitioners
  18. Discussion
  19. Conclusions
  20. References
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Authors Dr Jose Luis Portero (corresponding author) and Dr María Rubio, Tuberculosis Research and Training Center, Epidemiological Unit, Central Chest Clinic, Tayuman St (corner Rizal Av.), Santa Cruz, Metro Manila, 1003 Philippines. Tel.: +63 2 711 6195; Fax: +63 2 711 6654; E-mail: jporteronavio@yahoo.com, mrubioyuste@yahoo.es