Public Health in Private Hands. Studies on private and public tuberculosis care in Ho Chi Minh City, Vietnam

Abstract

Aim: This thesis assesses and compares private and public tuberculosis (TB) care in Ho Chi Minh City (HCMC), Vietnam, with an aim to identify suitable roles for private and public health care providers in tuberculosis control. Research framework: A set of standardised strategies for TB control advocated by the World Health Organisation and the International Union Against Tuberculosis and Lung Diseases is used as a framework to analyse private and public providers' ability to deliver care of adequate quality. The results of these analyses are contrasted with analyses of quality of care from an individual patient perspective. The current and potential future role of public and private health care financing and provision in TB control are discussed in relation to a traditional view that tuberculosis control is a public health concern for which the state has a prime responsibility. Further, the findings are discussed in the context of ongoing health sector reform in many low- and middle-income countries characterised by increasing private provision and financing of health care services. Methods: Attitudes towards private and public TB care among physicians and patients were investigated through two qualitative interview studies including 27 private and non-private physicians and 26 tuberculosis patients, respectively. Health care utilisation patterns and experiences of private and public TB care were described in a cross sectional survey of 801 new patients attending the national tuberculosis control programme. Magnitude and quality of anti-TB drug dispensing at private pharmacies were assessed in a cross-sectional survey of 147 private pharmacies. Quality of case-management and treatment outcome in a semi-private lung clinic and in the National Tuberculosis Programme (NTP) were assessed and compared in a prospective cohort study including a total of 502 tuberculosis patients.Results: About 40% of all people with TB in HCMC are treated by private providers. There is no strong socio-economic gradient between those who utilise private providers and those who do not. The findings indicate that quality of diagnostic procedures and case-management as well as treatment outcome is worse among private health care providers than in the NTP. Yet, private providers are popular options for patients. People perceive private physicians to provide individualised, easily accessible care at a cost that is not always higher than in the national tuberculosis control programme. Though treatment is free of charge in the NTP, some patients experience heavy costs associated with loss of time due to complicated administration of diagnostic procedures and directly observed treatment. Lack of privacy and a perceived stigma attached to the public tuberculosis treatment institutions have a deterring effect on some patients. Conclusions: The findings in this thesis show that private tuberculosis care in Ho Chi Minh City is of insufficient quality. The thesis identifies strong adverse effect on tuberculosis control associated with a private tuberculosis care market characterised by weak regulation, fee-for service payments and absence of third party financing and control of care. The national tuberculosis programme applies a control strategy grounded in a public health perspective on tuberculosis control that seem to lack flexibility and responsiveness to individual patients' needs. A strong public health focus in the planning of tuberculosis control may have paradoxically adverse public health effects if it is not combined with strong efforts to enable health care staff and patients to develop partnerships built on mutual trust and responsiveness to patients' individual needs.