Improving tuberculosis diagnosis in South Africa’s private sector: the results of a pilot public-private mix intervention in eThekwini health district

Abstract

While tuberculosis (TB) is primarily addressed in South Africa’s public sector, people with TB also present to private sector General Practitioners (GPs), where TB may be missed or treatment delayed. We introduced a pilot project in a high-TB burden health district to connect private GPs to free public sector TB testing. We aimed to gauge GPs’ willingness to participate and describe TB patterns in the private sector. GPs practicing in metropolitan eThekwini from May 2021-March 2022 were invited to participate. Recruited GPs were provided sputum specimen jars, specimen transportation, and access to free TB testing through the National Health Laboratory Service for clients with TB-like symptoms. A customized electronic form on an established medical referral application (Vula) was developed to record client information, initiate specimen transport, share real-time test results, and communicate management guidance. Of the 313 eligible GPs, 158 (50.5%) agreed to participate, among whom 61 (38.6%) submitted at least one client specimen (median=6, IQR=2-12). Specimen yield (17.6%) and quality (99.7%) were high. One-hundred- seven clients were diagnosed with TB, 39.3% were female and 48.6% were living with HIV. Three clients (2.9%) were diagnosed with drug-resistant TB. One hundred people with TB (93.4%) were linked to treatment, 96.0% in the public sector, in an average of two days (IQR 1-5), with 88/100 completing treatment in a median 182 days (IQR=170- 194). Two people with TB died before diagnosis by culture and six died during treatment, resulting in 7.5% case fatality (8/107). User-prompting to check HIV status significantly improved the frequency with which GPs enquired about HIV compared to a previous study (88.4% versus 25.7%, p<0.0001). One-fifth (19.5%) of GPs submitted specimens without monetary incentives and helped link 100 clients to TB treatment expeditiously, suggesting a successful pilot and a workable model for improving TB management in South Africa’s private sector.