| BackgroundTuberculosis remains a major challenge to global public health. In order to accelerate Tuberculosis (TB) care and control, the WHO proposed Public-Private Mix (PPM) strategy, which aimed at involving all the TB entities and practitioners to overall implement comprehensive control based on the Directly Observed Treatment Short Course (DOTS) strategy. In China, a diversified collaboration strategy, involving medical institutions (hospital) and professional TB control sectors (TB dispensary or TB Unit under the CDC), for TB care control has been formed during practical work, that is, the hospital-dispensary collaboration. There have been some international studies on the characteristics and effectiveness of PPM, and national researches on patients detection, referral and treatment outcomes. However, studies on summary of collaboration mechanism and model, or systematic evaluation for partnership effectiveness were rarely seen.ObjectivesTo systematically identify global PPM programmes, summarize the partnership mechanisms, narrate the characteristics, roles and responsibilities of involved sectors, and assess their effectiveness of TB control; to study the development, models and characteristics of the hospital-dispensary TB collaboration in China; to study the development, advantages and barriers of models for hospital-dispensary TB collaboration in Chongqing, investigate the present situation of centralized diagnosis, treatment and management for patients, in order to provide scientific evidence for solving the problems during collaboration process and promoting the health service for TB patients.Methods1. Systematic review was performed to summarize the mechanism and assess the effectiveness of PPM programmes.Publications until April2012were identified by a search in14electronic databases, two gray literature databases and six relevant websites. Original studies of description and evaluation for PPM programmes were included. Two researchers independently screened, sorted and extracted the data, disagreements were discussed and reach consensus. Qualitative approach was adopted to summarize and synthesize data, to draw the collaborative mechanisms and effectiveness of PPM prgrammes.2. Literature review, document collection and experts consultation were performed to study the hospital-dispensary TB collaboration and its collaboration models.We reviewed literatures and materials of hospital-dispensary TB collaboration in China, collected documents of related policy and law, and consulted national and international professionals, to summarized the establishment and development of hospital-dispensary TB collaboration, then overall summarize and analyze characteristics, advantages and limitations of main collaboration models.3. Facility-based survey, document collection, questionnaire investigation and qualitative interview were conducted to compare and analyze the characteristics, advantages, limitations and effectiveness between two TB collaboration models in Chongqing.Facility-based survey and document collection:we obtained data from involved sectors using sector survey forms, looked up policy and law from sector documents. Data was extracted and categorized, then descriptively statistic analysis was performed to detect variations of patients visits, diagnosis and trace between two modelsQuantitative investigation:we investigated494newly diagnosed TB patients through self-designed questionnaire from June to December2012, to collect their basic information, visits and referral situation. The data were double entered using EpiData3.1and analyzed by SPSS17.0Qualitative interview:ten leaders and outpatient physicians were organized by purposive sample. Key informant interviews were performed using semi-structured topic guides to understand the development, operation, characteristics, advantages and barriers during work. Data was managed by MAXQDA11software and analyze using framework approach.Results1. Results from systematic reviewA total of69studies were included and categorized into43PPM programmes implemented among15countries. The collaborative mechanism could be summarized in three mechanisms as the support mechanism (financial, material and personnel), contract mechanism (formal and informal) and working group mechanism (working group committee) according the roles and responsibilities of involved sectors. Most studies indicated that PPM could improve the effectiveness of TB control programmes in the aspects of DOTS utilization, case detection, treatment outcomes, case management, accessibility and equity, costs, technical capacity, acceptability and cooperation.2. Results from study on Chinese hospital-dispensary TB collaborationA diversified collaboration strategy for TB control was developed in China. The main collaborative models include dispensary model, designated hospital model, special hospital model and Primary health service network model. Hospital-dispensary TB collaboration played an important role in TB care and control in China, however, limitations also existed such as informal diagnosis, treatment and referral, limited personnel and technical capacity, poor management and so on. 3. Results from study on collaboration models of hospital-dispensary in ChongqingPresently the main TB collaboration models in Chongqing were dispensary model and designated hospital model. The dispensary model could ensure the systematicness and coherence of patients diagnosis, treatment and management; the designated hospital model could improve patients detection and tracing. The successful treatment rates and cure rates of TB patients in both the two models reached90%, and the dispensary model was littler higher. Two models could achieve relatively good outcomes but have some limitations, mainly like insufficient financial input, poor infrastructure and medical condition, lack of staff, short in training, low wages and incentives, incomplete health insurance, high infection risk of physicians and poor adherence of patients.ConclusionGlobal public-private mix strategy and Chinese hospital-dispensary collaboration strategy have diverse mechanism and models. Different models could play important roles in TB control practice due to their own advantages. As to cope with difficulties and barriers during the TB control work, we could make improvement from three levels of establish policy and law, promote sector work and develop new measures for treatment and diagnosis, specifically in the aspects of increasing fund input, specifying the responsibility of involved sectors, setting supervision systems, establishing information platform, promoting wages and incentives, improving insurance, applying related funds, reinforcing cooperation, enhancing training and education, modifying working methods, in order to improve PPM and hospital-dispensary collaboration and achieve success in TB care an control. |
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