Delivering Patient-Centered Care in a Fragile State: Using Patient-Pathway Analysis to Understand Tuberculosis-Related Care Seeking in Pakistan

Abstract

BackgroundPakistan has the sixth largest population in the world and boasts the fifth greatest burden of tuberculosis. The Government of Pakistan has set the ambitious goal of zero deaths due to tuberculosis and universal access to tuberculosis care by 2020. Successfully reaching these goals is dependent on the country’s capacity to diagnose and successfully treat an estimated 200000 unnotified or missing patients with tuberculosis.MethodsA patient-pathway analysis (PPA) was conducted at the national level, as well as for each of the 4 provinces, to assess the alignment between patient care seeking and the availability of tuberculosis diagnostic and treatment services.ResultsAlmost 90% of patients initiated care in the private sector, which accounts for only 15% of facilities with the capacity for tuberculosis diagnosis and treatment. Across the country, nearly 50% of tuberculosis microscopy laboratories were located in public-sector–basic health units and regional health centers. However, very few patients initiated care in these facilities. Overall, tuberculosis case detection was high given the low likelihood of patients reaching facilities with the capacity for tuberculosis service delivery during their first visit.DiscussionImproving the engagement of the informal sector and lower-level clinicians will improve the efficiency and timeliness of tuberculosis diagnosis for patients in Pakistan. Concurrently, the apparent strength of the referral networks connecting community-level workers and private clinicians to the public sector for tuberculosis diagnosis and treatment suggests that strengthening the capacity of the public sector could be valuable.

How do private practitioners in Pakistan manage children suspected having tuberculosis?

“…Across Pakistan treatment services are also available in the public facilities that have diagnostic capacity. Perhaps due to lack of trust in public sector to provide quality care, few patients sought care in the public sector [6]. It is possible that some referred TB patients might not actually go to NTP, and perhaps received treatment in the private sector.…”

“…A flow chart for evaluation of a child with suspected TB is given in Fig 1. A recent patient-pathway analysis in Pakistan confirmed the important role of the private sector in providing TB care in Pakistan, and highlighted the extent of utilization of private sector (85%) by the patients as entry points to care. [6] This is crucial for understanding the role of the private sector in the diagnosis and treatment of paediatric TB, and limited evidence is available on this issue [7,8].…”

Is the public-private mix approach increasing tuberculosis case notification in Azad Jammu and Kashmir, Pakistan? A cross-sectional study

“…Therefore, the private sector is relying more on X-ray based diagnosis rather lab based diagnosis 22 . Laboratory based diagnosis in the private sector is limited and more than half of all presumptive TB cases in the private sector is referred to the public sector for diagnosis 23 .…”

How do private practitioners in Pakistan manage children suspected having tuberculosis?

“…A ow chart for evaluation of a child with suspected TB is given in Fig 1. A recent patient-pathway analysis in Pakistan con rmed the important role of the private sector in providing TB care in Pakistan, and highlighted the extent of utilization of private sector (85%) by the patients as entry points to care. [6] This is crucial for understanding the role of the private sector in the diagnosis and treatment of paediatric TB, and limited evidence is available on this issue [7,8]. Therefore, we aimed to assess the practices of private health care providers in investigation of children suspected having TB.…”