Private tuberculosis care provision associated with poor treatment outcome: comparative study of a semi-private lung clinic and the NTP in two urban districts in Ho Chi Minh City, Vietnam. National Tuberculosis Programme.

SETTING: Ho Chi Minh City, Vietnam. OBJECTIVE: To compare tuberculosis case management and treatment outcome between a semi-private chest clinic and a publicly run national tuberculosis programme (NTP). METHOD: Prospective, non-randomised, comparative cohort study. Case-management and treatment outcome was determined for 176 patients treated in the semi-private clinic and 326 patients treated in the NTP. RESULTS: In the semi-private clinic cohort, significantly fewer patients completed treatment and/or were cured than in the NTP cohort (48.9% vs. 85.0%, P < 0.001). Among patients with sputum-positive pulmonary TB, significantly fewer were cured in the semi-private clinic cohort compared to the NTP cohort (22.2% vs. 79.2%, P < 0.001), and treatment success was significantly lower (35.2% vs. 79.7%. P < 0.001). Adjustment for a number of potential confounders did not change these findings significantly. CONCLUSIONS: Treatment outcome was considerably better in the NTP than in the semi-private clinic. The difference is not likely to be due to differences in patient characteristics or in provider knowledge. Different financial incentives for the providers in the two settings and ways of paying for services by patients are possible reasons for the observed difference in the quality of case management and treatment outcome.

Can I afford free treatment?: Perceived consequences of health care provider choices among people with tuberculosis in Ho Chi Minh City, Vietnam.

Vietnam has a well-organised National TB Control Programme (NTP) with outstanding treatment results. Excellent prospect of cure is provided free of charge. Still, some people prefer to pay for their TB treatment themselves in private clinics. This is a potential threat to TB control since no notification of cases treated in the private sector occurs, and there is no control of the effectiveness of treatment provided in private clinics. Using a qualitative approach within a grounded theory framework, this study explores health-seeking behaviour among people with TB, applying a specific focus on reasons for choices of private versus pubic health care providers. The study identifies a number of characteristics of private TB care, which both seem attractive to patients and at the same time contrast sharply with the structure of the NTP strategy. These include flexible diagnostic procedures, no administrative procedures to establish eligibility for treatment, flexible choices of drug regimens, non-supervised treatment (no DOT), no tracing of defaulters in the household, no official registration of TB cases and thus less threat to personal integrity. A possibility to demand individualised service through the use of fee-for-service payments directly to physicians also seems attractive to many patients. A number of the components of the NTP strategy that have been put in place in order to secure optimal public health outcomes are lacking in the private sector. A dilemma for TB control is that this seems to be an important reason for why many people with TB opt for private providers where quality of care is virtually uncontrolled. The global threat of TB has led to calls for forceful measures to control TB. However, based on the findings in this study it is argued that the use of rigid approaches to TB control that do not encompass a strong component of responsiveness towards the needs of individuals may be counterproductive for public health.

Utilization of private and public health-care providers for tuberculosis symptoms in Ho Chi Minh City, Vietnam.

In Vietnam, as in many other countries, tuberculosis (TB) control has long been organized exclusively within the public health-care system. However, recently the private health-care sector has become more important and private health-care providers currently have a role in TB care delivery in Vietnam. Through a retrospective survey of patients at District Tuberculosis Units (DTUs) of the National Tuberculosis Programme in Ho Chi Minh City, we investigated utilization of private and public health-care providers among people with symptoms of TB. Eight hundred and one patients in eight DTUs were interviewed. For the current illness episode, about half of the patients had initially opted for a private health-care provider. Twenty-seven percent had been to a private physician and 31% to a private pharmacy at some time during their current illness. We found no significant association between socioeconomic status and use of private health-care providers. Utilization of private health-care providers among people with TB or symptoms of TB in Ho Chi Minh City seems to be similar to the general utilization of private providers in Vietnam, at least before TB is diagnosed. Since a large proportion of people with TB in Ho Chi Minh City across all economic and social strata consult private providers at some time during their illness, planners of TB control strategies need to consider both the health-care seeking behaviour of people with TB and the clinical behaviour of private providers, in order to secure early detection of TB, early initiation of appropriate treatment, and maintenance of appropriate treatment.

Delay and discontinuity--a survey of TB patients' search of a diagnosis in a diversified health care system.

SETTING: Ho Chi Minh City (HCMC), Vietnam. OBJECTIVES: To describe delay to diagnosis; to compare diagnostic procedures and referral routines used by private and public health care providers; and to examine associations between contact with various types of providers and risk of delay to TB diagnosis. DESIGN: Cross-sectional survey of new patients in the National Tuberculosis Programme (NTP). Retrospective assessment of health seeking and diagnostic procedures used by previously contacted health care providers. RESULTS: Four weeks after first symptom, 81% of patients had sought help outside the household. Four weeks after first health care contact, 47% had been diagnosed with TB. Private physicians used X-rays, sputum smears, and referrals significantly less often than public health care providers. Patients who had turned first to a private pharmacy, a private physician or a public hospital were significantly more likely to have a long provider delay than those who turned first to the NTP. CONCLUSION: Delay to diagnosis of TB in HCMC is due more to inability among health care providers to detect TB than to under-utilisation of health care services. Diagnostic procedures need to be improved and referral chains need to be strengthened in HCMC, particularly among private providers.

Risks and benefits of private health care: exploring physicians' views on private health care in Ho Chi Minh City, Vietnam.

As in a number of other low- and middle-income countries, the health sector in Vietnam is transforming with a rapid shift from fully state run and financed health care towards more private financing and delivery of health care. This development has been particularly noticeable in the largest city in the country, Ho Chi Minh City, where a majority of physicians now are practising in private clinics and where the private health care sector is an increasingly popular option for people. While the private sector is an important part of the health care system in Vietnam, few data are available on the characteristics and quality of private health care services. This case study describes some aspects of the re-emerging private health care sector in Ho Chi Minh City, Vietnam, from the view of 27 private and non-private physicians. The paper explores physicians' reasons for going private, physicians' notions of patients' health care preferences, and physicians' views on potential influence of financial incentives on characteristics of private health care. The characteristics of private health care are discussed in relation to a context of private health care characterised by a fully patient-financed fee-for-service payment system, weak regulatory mechanisms, and a public health care system (government-run and-financed health care) that operates under resource constraints. Issues to consider when attempting to steer private health care in Vietnam in a direction where it can optimally contribute to public health, are discussed while considering the interplay between authorised private practitioners, private pharmacies, the informal private sector, and the public health care sector.