Abstract:
Introduction: Tuberculosis exacts heavy morbidity and economic tolls globally – more than ten million incident cases and $9.2 billion of tuberculosis (TB) expenditure accrued in 2017 alone. The World Health Organization introduced the Public-Private Mix (PPM) initiative in the late 1990s as part of measures to achieve TB control targets by strategically engaging all health providers. Ghana, one of the thirty high-burden TB nations implemented PPM in 2003 in urban areas of the country. Whilst TB treatment success rate in Ghana is on a par with global targets, national TB case notification has been declining steadily. Also, the PPM initiative is yet to be scaled-up in Ghana. The evidence from several studies in different locales suggest that the performance of PPM is highly dependent on the context within implementing areas. It is unclear what contextual factors affect the PPM initiative in Ghana and what the trends in case notification in the implementing areas are.
General objective: To explore factors affecting Public-Private Mix strategy for TB care and control in urban areas in Ghana.
Methods: Twenty-three in-depth interviews, using a semi-structured interview guide, were carried out with TB coordinators involved in PPM-TB within the Accra and Kumasi Metropolitan areas of Ghana. Quantitative data on TB cases notified in Accra Metro (2007 to 2018) and Kumasi Metro (2012 to 2018) were obtained with a data extraction form to describe trends in case notification. The autoregressive moving average (ARIMA) method was used to forecast TB case trend for 2019.
Results: The most prominent amongst health system factors affecting PPM implementation included funding constraints, poor monitoring and supervision, and high attrition rates of trained TB workers. The involvement of an implementing partner (Aurum Institute) since 2018, is facilitating PPM in the urban areas. Case notification has been declining, with Kumasi Metro notifying persistently lower rates than Accra Metro. Predictive modelling forecasted a potential change of 4.5% and -0.3% in the expected 2019 annual notification rate for Accra and Kumasi Metros respectively.
Conclusion: The PPM initiative has declined in productivity since it was initially rolled out, but holds potential for improvement and scale-up if strengthened.
