HERD - NEPAL

Development of guidlines to assist national implementation of a public-private partnershipfor TB control in Nepal

The World Health organisation advocates that any person with a cough of more than 2 weeks duration should be investigated for TB. In Asia, 50% or more of such people initially seek diagnosis and treatment from a private medical practitioner (PP). Unfortunately, PPs generally provide poor diagnostic services and treatment. Public-private partnerships (PPPs) for TB control can be used to take advantage of the strengths of various players in TB care: PPs as the first contact with TB suspects; public and NGO health services that can provide high quality care, recording and reporting; and the NTP who can provide free drugs for TB patients and guidance to PPs on how best to diagnose TB. PPPs thus give us an opportunity for substantial DOTS expansion.

In 1995, the NCIHD developed and tested a PPP in Lalitpur Municipality, Nepal. The study found that the PPP had more than doubled the case-finding rate in the project area, while maintaining treatment success rates at a very high level. Despite the success of the PPP in Lalitpur, expansion to other cities and towns in Nepal has been slow. Currently, there is little guidance on how to expand these pilots country-wide. About 28,000 TB cases occur annually from urban areas of Nepal. The expansion of the PPP will benefit patients from provision of high quality and accessible DOTS services, and the population from reduced risk of transmission of TB. It is therefore appropriate to develop guidelines for expansion of PPPs to other cities and towns in Nepal, and more widely across Asia.

The study aims to evaluate guidelines for expansion of PPPs to the cities and towns of Nepal; and to prepare a generic version of PPP guidelines for use in other countries. The study area will be cities and towns of Nepal. Guidelines for PPP expansion will be developed using a team approach, involving members of the Nepal NTP, HERD, NCIHD and representatives from PPs and municipalities.

The usefulness of the guidelines will be assessed using mixed quantitative and qualitative methods. Qualitative methods will compromise TB control outcomes and assessments of population coverage. The numbers of people covered by PPPs after 2 years, case-finding rates and treatment success rates before and after introduction of PPPs will be compared. Interviews will be conducted with NTP staff, Municipality staff, PPs involved in the PPP, NGO staff involved in the PPP, and patients. Interviews will be conducted using semi-structured questionnaires; and a thematic approach to analysis will be adopted. Key stakeholders from the NTP, the Municipality and StopTB will be involved from the inception of the research. The study findings will be submitted to international journals, other partners and those involved in development and implementation of TB control.