Private sector markets for tuberculosis drugs in some Asian
countries are providing enough drugs to treat every new TB case each year – but
in many cases patients appear to be receiving drug regimens that are not
recommended in international guidelines, according to a major survey published
in the journal PLoS One.
Although tuberculosis treatment is largely provided through
the public sector in the majority of countries with a high burden of
tuberculosis (TB), the coexistence of public and private medical sectors in
many Asian countries has led to large-scale dispensing of medicines with very
Until recently public sector TB control programmes were
underdeveloped in many Asian countries, leading to large-scale use of private
sector diagnosis and treatment.
As governments seek to scale up public sector TB responses
with the support of donors it has become clear that greater consistency in
treatment approaches between public and private sectors will be an important
part of limiting the emergence of multi-drug resistant TB.
For example, public sector programmes have been working
towards the adoption of a number of measures designed to limit the emergence of
drug resistance, including directly observed treatment during the intensive
phase of TB treatment, usually known as DOTS, the use of fixed-dose
combinations to improve adherence, and prescription of a very limited number of
different drugs based on recent information about drug resistance patterns in
In each case, promoting adoption of these practices in the
private sector has proved challenging.
one study found that 100 private sector doctors managed to prescribe 80
different TB regimens to their patients, while in the Philippines another study found
that 89% of TB prescriptions by private sector providers didn’t match national
However, there is little information about the size of
private sector TB treatment markets and the drugs prescribed within them that
would help national programmes begin to push for changes.
To help in mapping the role of the private sector in TB treatment the
Global Alliance for TB Drug Development carried out an international survey of
private sector providers with IMS Health, a healthcare market research company,
in 10 countries
representing 60% of the global TB burden (Bangladesh,
China, India, Indonesia,
Pakistan, Philippines, Russian
Federation, South Africa,
Thailand, and Viet Nam).
The most significant
finding was the sheer volume of drugs being prescribed in the private sector,
and the extent to which total national prescribing in both public and private sectors
appeared to exceed the national burden of TB, in some cases by 60 to 80%.
In India, for example, the total volume of TB drugs
prescribed for first-line treatment by the private sector in India would
treat 117% of the incident TB cases reported in 2008-2009. In Indonesia the volume of prescriptions was
equivalent to 116% of incident TB cases, in the Philippines
86% and in Pakistan
Where did all these
drugs go? The researchers suggest that many patients who present for care to
public facilities may already have received treatment in the private sector;
indeed they note that in India,
86% of patients in one study had first sought care in the private sector.
It is also possible
that a large number of cases of TB never get reported properly, despite drug
However, two other
practices may also be contributing to the large volume of prescribing: the
tendency of private sector physicians to prescribe TB drugs for longer than
recommended in international guidelines, and the use of TB drugs to treat
The study also found
that at least one-third of all private sector dosages of first-line TB drugs
fall outside of national and international treatment recommendations. No less
than 111 different first-line TB drug dosages and combinations were being
prescribed in the private sector across ten countries, compared to the 14
deemed necessary by the Stop TB Partnership's Global Drug Facility.
Although a large
proportion of first-line TB treatment is being prescribed by the private
sector, very few patients with multi-drug resistant TB receive treatment in the
private sector, and where MDR-TB treatment is being prescribed, the low volumes
of many oral drugs recorded in the survey suggests that it is sub-optimal.
national guidelines favour the use of fixed-dose combinations for TB treatment
because it helps adherence to medication and ensures that the right doses of
drugs are dispensed. While India,
Pakistan, Philippines, Bangladesh
and South Africa
had relatively high volumes of fixed-dose combination prescription in the
private sector, greater than 90% of first-line TB prescriptions in the
remaining countries still come in the form of loose TB drugs.
countries appeared to have high levels of prescription of first-line TB drugs
at non-standard dosages, which carries a clear risk of either inadequate drugs
levels in the case of too-low dosages (most common in China) or side-effects
leading to treatment discontinuation in the case of too-high dosages (most
common in India). Thirty-five per cent of all first-line TB drugs prescribed
across the ten countries were non-standard dosages.
private sector treatment were also paying high prices for TB drugs; on average,
almost twice the price at which drugs were supplied to the public sector. An
average course of first-line TB treatment in most countries was at least $50,
suggesting another reason why so many patients either failed to complete a
course of TB treatment, or present to public sector TB clinics after a period
of private TB treatment.
covered in this study have public-private
mix (PPM) programmes for TB care," said Mario Raviglione, Director of
the Stop TB Department at the World Health Organization.
"Based on country
experiences, these programmes have shown good results in optimising TB
management by private care providers. However, the size of the response is not
commensurate with the size of the challenge; there is enormous scope to expand
these programmes urgently.”
He recommends that private
providers following best practices should be supported through accreditation
and access to free TB drugs from the public sector, while those not doing so
should be regulated.
and international support is needed for these efforts and also for improved
regulatory oversight and quality assurance of TB drugs. A dual track approach
of collaboration and regulation is the logical way forward. We ought to make
private providers responsible partners of the public sector in controlling TB