Involvement of the private sector in TB care through integrated disease management approach in South Africa
Using the private sector to address public health concerns is an underutilised resource that can, in this instance find the missing TB cases, and improve the quality of care amongst patients diagnosed with TB. Through partnerships with the Independent Private Practitioners Association of Port Elizabeth, District Health Management Team, and the community of Port Elizabeth (through the local administration), the project was able to introduce TB screening in the community, and integrate TB management in the private health sector, amongst participating GPs). The project was able to demonstrate feasibility of utilising the private sector to manage public health diseases (TB), using the NHI strategy as the guiding policy. Read More
This is important as it demonstrates that this strategy is feasible, as it addresses most of the key components of the NHI bill (involving the private sector, maintaining quality of care, financial prudence). Preliminary results, despite several challenges encountered in the project set up, include identifying 748 patients in the private sector, integrating GP reporting into the government database, integrating molecular testing in the private sector – at no cost to patient, and TB medicines in the private sector – at no cost to the patient.
Linking the GPs to Public Health Facilities also means the public health facilities, which are mostly staffed by nurses, have access to Medical Doctors (GPs) which should improve; referrals between government and private sector, and capacity of both private and private sector.
52% of households in NMBM are female headed often relying on a single income for survival which creates gender-based inequality and inequity. The project has focused on recruiting more than 80% women in the project and has capacitated them to manage the project. The project coordinator (a women) has also been involved in proposal writing to improve the sustainability of the project.
AQUITY is optimistic about sustaining the project as the project is a pilot of the NHI bill – outsourcing of health services to the private sector. The project, a successful recipient of the Global Fund grant for TB in South Africa, has also had the opportunity to integrate elements of the TB Reach project in the implementation districts. Results of the project – including outcome results, will also be presented to the National Department of Health as a scalable NHI project.
Nelson Mandela Metro Bay is one of the 19 high burden districts that account for up to 80% of the national TB burden . Nelson Mandela Metro, where the project was implemented spans 2,000 km² and is characterized by sprawling subdivisions with high crime, scarce access to public health facilities, and tight living quarters. The population of the evaluation district, where intervention was implemented was 518,690, with a control population of 440,298. Private sector GPs practice in these subdivisions out of small clinics. These clinics are preferred by residents despite high costs because they are often closer than the nearest health facility and may have more accessible opening times. There are about 180 private practices compared to 50 public health facilities. Read More
Private facilities provide diagnostic services and referral to public health facilities of diagnosed patients. Diagnostic services are provided at a fee with GeneXpert in the private sector not subsidised, at an average of $40 to $60, compared to smear microscopy at $1. These services are available for free in the public health facilities. Molecular testing is the primary diagnostic tool according to the South African TB guidelines.
Our intervention was a unique pilot of private-public mix in a South African context. We engaged private sector providers – general practitioners (GPs) – in the Eastern Cape province of South Africa in diagnosis, treatment and care of people with TB. Taking advantage of an extensive GP infrastructure already in existence, the project seeks to integrate molecular testing and capacity support for GPs to increase access to TB management.
 South Africa’s National Strategic Plan for HIV, TB and STIs 2017 – 2022
Project activities/interventions implementation
Recruitment and Training of GPs
Port Elizabeth has a network of independent general practitioners, who meet on a regular basis to discuss to address issues that affect patient management in the private sector. AQUITY engaged the Independent Private Practitioners Association to brief them on project and how it interlinks with the National Health Insurance (NHI) bill. The project recruited general practitioners from the IPPA based on their geographic location (the intervention area), and interest in participating in the intervention. A total of 10 private GPs were trained in recognizing symptoms and diagnosing TB in accordance with national TB guidelines. The project also expanded private GPs access to GeneXpert testing through collaboration with the public sector. Read More
All TB related services were provided by GPs for free. GPs received a fee of ZAR 574 per hour for 5 hours of work per week (approximately US $49 per week considering exchange rates at the time of project execution).
Recruitment and Training of Community Health Workers
A total of 20 female CHWs from the communities in the GP’s catchment areas were also hired and trained in active case finding. Topics covered included: door-to-door screening; sputum collection; recording and reporting; patient management and support; TB education and project management. I think it’s important to also say something like this here: Through the course of the project it was recognized that CHWs who were originally from the area where they conducted the screening and house-to-house visits were generally better received by the community and more safe, when assigned to an area that was not familiar to them.
CHW were remunerated at the rate of 4,500 per month, based on South Africa’s CHW salary guidelines.
During the course of project implementation, AQUITY Innovations requested a budget realignment to increase number of CHWs to 30 and introduced a new cadre of Community Health Care Workers Team Leads (CHW TLs). This was based on a mid-term review to increase quality and quantity of community screening, and consequently increase case detection in the private sector.
Patient Diagnosis and Treatment
A small cadre of CHWs (3) was assigned to each GP and GPs and CHWs collaborated in finding, diagnosing, reporting and case managing people with TB. CHW conducted door-to-door and contact tracing activities in the vicinity of the assigned GP office. CHWs utilized the NDoH TB screening tool, based on the WHO questionnaire, and collected sputum samples from individuals with symptoms and brought samples to GPs. Alternatively, GPs and clinic staff collected sputum from individuals with suspected TB attending the clinic, who reported symptoms on the symptom screen implemented by clinic staff. Sputum testing was prompted by GPs for both samples collected in clinic and in the community and Xpert tests were conducted at the nearest public sector lab.
Through the project, private GPs were granted access to LabTrak – an electronic lab results management system -which allowed them to register, and track results of the sputum sent for testing. A project nurse coordinator also tracked hard copies of lab results to ensure all diagnosed patients accessed treatment. Effective patient data management was secured through data management standard operating procedures developed specifically for the project.
Following this electronic and paper trail, CHW followed up with individuals with confirmed TB and brought them for consultations and treatment initiation by GPs. GPs had to register in the TB HIV Integrated System (THIS) to be eligible to distribute TB treatment. GPs also conducted HIV screening and testing and could provide concurrent support for individuals with HIV and TB. CHWs and GPs provided treatment support over the course of TB treatment and ensured treatment completion through repeated testing, home visits by CHWs, and phone calls by GPs.
Summary of Project Process Indicators
Percentages for each intervention
Impact on Case Notifications
Achievements, Challenges, and Lessons
The project has successfully piloted the PPP project in Port Elizabeth with successful engagement of the stakeholders, with buy in being secured from the Private Practitioners Association, District Health Management Team, as well as the provincial health leadership. This was evidenced by the representation at the project launch.
While anecdotal evidence that the NHI fee for service would not be feasible in the private sector due to high disparities from the fees charged by the private sector. The average consultation is $42, excluding the cost of testing, medication and follow up. Read More
Community buy in was also secured with over 161,976 community members having been screened for TB. Over 748 TB patients were identified through the project.
Key successes also included being able to obtain free TB medicines (government procured) for the private practitioners in the project, this also included access to molecular testing (GeneXpert), as well HIV testing kits for private practitioners in the project.
The success of stakeholder engagements was also realized with the taxi association donating a converted container to function as a testing and adherence center.
The project despite significant buy-in from stakeholder delayed in realizing anticipated yields. The project successfully realigned to increase number of community health care workers as well as team leads to assist with the project coordination, and to implement revised strategy – targeting contacts.
Data management was also challenge, particularly when establishing additionality. The government database reports are usually incomplete by the reporting period. In the scale up phase, the project has requested data capturers to ensure capturing of initiated patients is up to date.
The project has also integrated mapping of screened patients to identify clustering and hotspots for more targeted screening. This will also assist the government to target their interventions, particularly during commemorative events.