High use of private providers for first healthcare seeking by drug-resistant tuberculosis patients: a cross-sectional study in Yangon, Myanmar

Abstract

BackgroundDrug resistance is a growing challenge to tuberculosis (TB) control worldwide, but particularly salient to countries such as Myanmar, where the health system is fragmented across the public and private sector. A recent systematic review has identified a critical lack of evidence for local policymaking, particularly in relation to drivers of drug-resistance that could be the target of preventative efforts. To address this gap from a health systems perspective, our study investigates the healthcare-seeking behavior and preferences of recently diagnosed patients with drug-resistant tuberculosis (DR-TB), focusing on the use of private versus public healthcare providers.MethodsThe study was conducted in ten townships across Yangon with high DR-TB burden. Patients newly-diagnosed with DR-TB by GeneXpert were enrolled, and data on healthcare-seeking behavior and socio-economic characteristics were collected from patient records and interviews. A descriptive analysis of healthcare-seeking behavior was followed by the investigation of relationships between socio-economic factors and type of provider visited upon first feeling unwell, through univariate logistic regressions.ResultsOf 202 participants, only 8% reported first seeking care at public facilities, while 88% reported seeking care at private facilities upon first feeling unwell. Participants aged 25–34 (Odds Ratio = 0.33 [0.12–0.95]) and males (Odds Ratio = 0.39 [0.20–0.75]) were less likely to visit a private clinic or hospital than those aged 18–24 and females, respectively. In contrast, participants with higher income were more likely to utilize private providers. Prior to DR-TB diagnosis, 86% of participants took medications from private providers. After DR-TB diagnosis, only 7% of participants continued to take medications from private providers.ConclusionIn urban Myanmar, most patients shifted to being managed exclusively in the public sector after being formally diagnosed with DR-TB. However, since the vast majority of DR-TB patients first visited private providers in the period leading to diagnosis, related issues such as unregulated quality of care, potential delays to diagnosis, and lack of care continuity may greatly influence the emergence of drug-resistance. A greater understanding of the health system and these healthcare-seeking behaviors may simultaneously strengthen TB control programmes and reduce government and out-of-pocket expenditures on the management of DR-TB.

Do private health providers adhere to National Tuberculosis Guideline while assigning treatment outcome? Findings from a lower middle-income country

“…A World Health Organization (WHO) survey in Mexico showed that private practitioners managed one-third of patients who died from TB (14). Also, 85% of DR-TB patients were reported to have been previously managed for TB in the private sector (15). Despite the relatively high reported overall national TSR over the years, DR-TB case notification in Nigeria has increased from 21 in 2010 to 1,686 in 2016 and a further increase of 35% from 1,686 in 2016 to 2,286 in 2017 (2).…”

Knowledge of International Standards for Tuberculosis Care among Private Non-NTP Providers in Lagos, Nigeria: A Cross-Sectional Study

“…Section two contains 30 multiple-choice questions that assessed the knowledge of the participants with a different number of questions across the five standards categories based on the International Standard for TB Care TB. Standards assessed include knowledge of symptom and diagnosis (7), knowledge of treatment (10), knowledge of management of TB/HIV co-morbidity (2), knowledge of public health (7) as well as the TB patient rights charter (4).…”

“…It was reported that the percentage of initial care seeking was 74%, 74%, 70%, 85%, 67%, 84% and 88% in India, Indonesia, Philippines, Pakistan, Nigeria, Bangladesh and Myanmar, respectively [3,4]. Private non-NTP providers are defined as private providers who are not part of the NTP surveillance, including qualified providers from the private for-profit (PFP) and private not-for-profit (PNFP) sectors.…”

Healthcare seeking behavior and delays in case of drug-resistant Tuberculosis patients in Bangladesh: Findings from a cross-sectional survey

“…Patient delays and diagnostic delays depend on patterns of care-seeking of a patient. In South Asia, patients usually visit informal healthcare providers as the first point of care (13). Drug sellers, traditional healers, village doctors, ayurvedic, and homeopaths are recognized as informal healthcare providers in Bangladesh (14).…”