Public–Private Mix (PPM) for Tuberculosis (TB) in Urban Health Systems in Least Developed, Low Income and Lower-Middle-Income Countries and Territories – A Systematic Review

Abstract

Objective To assess the impact of Public-Private Mix (PPM) models for Tuberculosis (TB) diagnosis and treatment on health, process, and system outcomes within urban contexts of least developed, low Income, and lower-middle-income countries and territories (LMICs). Design Systematic review. Study selection Ten electronic databases and research repositories, covering published and grey literature were searched on 15 August 2022. All primary studies on PPM models delivering TB services in urban health sectors of eligible countries were included. There were no restrictions applied by type of outcome measurement, publication date, or language. Data extraction and synthesis Data were extracted on COVIDENCE and quality appraisals were carried out using the Mixed Methods Appraisal Tool (MMAT). Narrative synthesis was carried out by tabulating studies according to PPM model types (direct or interface), and assessing their performance on TB health, process (including cost-effectiveness) and system outcomes. Results Of the 55 included studies, covering quantitative (n=41), qualitative (n=5), and mixed-method (n=9) designs, the majority were from South-East Asia (n=36). PPM models had overall positive results on TB treatment outcomes, access and coverage, and value for money. They also promoted and improved TB health workers' skills and service delivery. Most outcomes tended to favour interface models, albeit with considerable heterogeneity. Inconsistent implementation of NTP guidelines, uncoordinated referrals, and lack of trust among partners were identified as areas of improvement. Evidence was lacking on involvement of informal providers within PPM models. Conclusions PPM models can be effective and cost-effective for TB care in urban LMIC contexts, particularly when levels of mistrust between public and private sectors are addressed through principles of equal partnership. The evidence indicates that this may be more achievable when an interface organisation manages the partnership. Study registration PROSPERO CRD42021289509.