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INT J TUBERC LUNG DIS 9(5):562–568
© 2005 The Union
Every provider counts: effect of a comprehensive public-private
mix approach for TB control in a large metropolitan area in India
G. Ambe,* K. Lönnroth,
†
Y. Dholakia,
‡§
J. Copreaux,
§
M. Zignol,
†
N. Borremans,
¶
M. Uplekar
†
* Mumbai Municipal Corporation, Mumbai, India;
†
Stop TB Department, World Health Organization, Geneva,
Switzerland;
‡
Universal Care Initiative for TB Control, Mumbai,
§
Inter Aide, Mumbai,
¶
Médecins Sans Frontières,
SUMMARY
Mumbai, India
SETTING: Mumbai, India.
OBJECTIVES: To assess impact on case notification and
treatment outcome of a public-private mix approach for
tuberculosis (TB) control involving private providers, non-
governmental organisations (NGOs), and public provid-
ers not previously involved in the Revised National TB
Control Programme (RNTCP).
METHODS: Under the stewardship of the RNTCP, pro-
viders were allocated different roles in referral, diagnosis,
treatment initiation, directly observed treatment (DOT)
provision, training and supervision. Referral forms were
introduced and RNTCP registers were adapted to enable
monitoring of case notification by different providers
and cohort analysis disaggregated by provider type.
RESULTS: A fraction of all non-RNTCP providers had
become actively involved by the end of 2003. These pro-
viders contributed 2145 new smear-positive cases in 2003,
an increment of 40% above the 5397 cases detected in
RNTCP facilities. The treatment success rate for new
smear-positive cohorts for 2002 was 85% in RNTCP fa-
cilities, 81% in private clinics, 88% in medical colleges,
91% in NGOs and 73% in the TB hospital (where the
death rate was 16%).
CONCLUSION: Active involvement of some key public
and private providers can increase case notification sub-
stantially while maintaining acceptable treatment out-
comes. The impact can be expected to be even larger
when all health providers have been involved.
KEY WORDS: tuberculosis; public-private mix; metro-
politan TB control; case detection
IN 2002, 69% of the world’s population was covered
by DOTS services, while only 37% of estimated new
smear-positive cases were notified and registered in
DOTS programmes.
1
This is only half way to the
70% case detection target for 2005.
2
There is cur-
rently a global quest for innovative approaches to im-
prove case detection of tuberculosis (TB). One way
forward is to actively involve all available health care
providers in DOTS expansion.
3
In many countries the existing public-private mix
(PPM) of health care providers has not been opti-
mally utilised for DOTS expansion. The for-profit
private sector is often poorly regulated and controlled
by the health authorities, and is therefore perceived as
being out of reach of public health programme plan-
ning and implementation. However, it seems that
many public sector providers are also out of reach of
public health programme implementation, often due
to a lack of coordination and joint central planning
between different Ministry of Health (MoH) depart-
ments as well as between the MoH and other ministries
responsible for health care provision in a variety of
sectors, such as the prison system, the armed forces,
educational systems and employee health insurance
schemes.
3
In large cities this situation is particularly compli-
cated due to the multiplicity of private and public
providers and of authorities. TB control coordination
between city, provincial and national administrations
poses complex problems related to the hierarchy of
bureaucracies and degree of autonomy. The problem
of too many authorities and providers is compounded
by a matching multiplicity of user groups with different
TB service needs: daily wage earners, slum dwellers,
day migrants and drug users. As a consequence, there
is often poor access to a wide range of weak services
available in metropolitan areas.
4
This is the situation also in India, where the Revised
National TB Control Programme (RNTCP) was im-
plemented in 1992 and two thirds of the country was
covered by 2003.
5
In facilities implementing the
RNTCP, the treatment success rate has been consis-
tently above 80%. However, the case detection rate
was only 31% in 2002.
1
A contributing factor for low
Correspondence to: Dr Knut Lönnroth, TB Strategy and Operations, Stop TB Department, World Health Organization, 20 Ave-
nue Appia, CH-1211 Geneva 27, Switzerland. Tel: (41) 22 791 16 28. Fax: (41) 22 791 42 68. e-mail: lonnrothk@who.int
Article submitted 4 June 2004. Final version accepted 15 September 2004.
PPM DOTS in Mumbai 563
case detection rates under DOTS is that many patients
are treated in health facilities that are not part of the
RNTCP.
The for-profit private health care sector treats a
large proportion of TB cases in India.
6,7
Several projects
have piloted approaches linking private providers
(PPs) to the RNTCP to improve case detection under
DOTS and to improve TB treatment quality in the
private sector. Based on documented successes in im-
proving case detection and treatment quality through
such approaches,
8,9
the RNTCP has developed strate-
gies for broader involvement of both the private
for-profit sector and non-governmental organisations
(NGOs) in TB control.
10,11
Many public health care providers also diagnose
and treat TB in an unstandardised manner outside the
RNTCP, without notifying cases. The RNTCP recently
developed strategies to involve all relevant public health
care providers in TB control. Few data are available
on the effectiveness of such approaches in India and
elsewhere. The current study assesses a strategy to in-
volve all relevant public and private health care pro-
viders in a large metropolitan area in India.
METHODS
Study setting
Mumbai has a population of 12 million, of which half
live in slums.
12
RNTCP implementation started in 1992
and reached 100% geographical coverage in 1999.
The RNTCP is implemented through the Mumbai
District Tuberculosis Control Society (MDTCS). Mem-
bers are representatives of all stakeholders involved in
TB control, such as medical colleges, the TB Hospital,
Mumbai District AIDS Control Society, private
chest consultants, NGOs and the Maharashtra Anti-
Tuberculosis Association. The city is divided into 6
administrative zones and 24 administrative wards.
The RNTCP is implemented through 22 TB units,
112 microscopy centres and 676 treatment centres. In
2001, the RNTCP facilities in Mumbai had a cure
rate of 83%. The case notification rate was 42 new
smear-positive cases per 100 000 population in 2001,
i.e., 56% of estimated incidence based on the national
annual risk of tuberculosis infection (ARTI).
13
Public providers controlled by local government
include four medical colleges, 21 secondary care hos-
pitals, one TB hospital, 26 maternity homes, 163 mu-
nicipal dispensaries and 176 urban health posts. Many
other health institutions are run by the State Govern-
ment, Central Government, Railways, Employees State
Insurance Scheme (ESIS), Port Trust and defence
establishments.
There are about 50 large private hospitals, 2000
nursing homes, and 8000–10 000 individual PPs prac-
ticing allopathic (modern), Ayurvedic, homeopathic
and Unani systems of medicine. The TB case load is
high, and TB management practices have previously
been very poor.
6,14,15
The numerous local NGOs in Mumbai play a role
in providing services for underprivileged TB patients
in the slums and integration into targeted communi-
ties. With the introduction of the RNTCP, many NGOs
have shifted their role towards social activities.
16
The intervention
The intervention was aimed at involving all relevant
providers in the RNTCP by identifying suitable roles
in DOTS delivery for various providers (Table 1).
MDTCS/RNTCP was responsible for setting standards
of care and for overall coordination, supervision,
quality control, monitoring and evaluation. Develop-
ment of tools for improving the referral and informa-
tion systems, sensitisation of providers, training and
field supervision was carried out in collaboration with
three NGOs: Médecins Sans Frontières (MSF), Univer-
sal Care Initiative for TB Control (UCITC) and Inter
Aide. Funding was from the RNTCP, with support
from the World Health Organization (WHO), while the
NGOs contributed staff time. All providers were in-
structed to follow the RNTCP guidelines. Drugs were
delivered by the RNTCP to facilities acting as directly
observed treatment (DOT) providers (DOT was pro-
vided thrice weekly in health care facilities). No fi-
nancial incentives were used. Non-financial incen-
tives for PPs included access to continuing medical
education free of charge, and access to free sputum
microscopy and quality-assured anti-tuberculosis drugs
for TB patients.
Involving additional public providers
After initial reluctance to implement the RNTCP, the
four medical colleges in Mumbai agreed to open
RNTCP out-patient departments run by chest physi-
cians working in close liaison with all relevant hospi-
tal departments. A core committee was established
under the chairmanship of the Dean in each medical
Table 1 Role division of different provider types in Mumbai
PPM initiative for improved DOTS implementation
RNTCP
Public
hospitals NGOs
Private
practitioners
Financing,
drug supply,
surveillance X
Training,
supervision,
monitoring X X
Referral of suspects X X X X
Diagnosis X X X
Treatment initiation X X
DOT provision X X X X
Defaulter retrieval X
PPM public-private mix; RNTCP Revised National Tuberculosis Control
Programme; NGO non-governmental organisation; DOT directly
observed treatment.
564 The International Journal of Tuberculosis and Lung Disease
college for coordination and effective implementation
of RNTCP. The 1000-bed TB hospital was involved
only after purchase of RNTCP drugs was stopped by
the intervention of a higher authority. The patients di-
agnosed at this hospital were given RNTCP drugs for
in-patient treatment and were then referred to the
nearest DOT centre. ESIS hospital involvement started
at the end of 2003 after the intervention of the secre-
tary of State Ministry of Labour, followed by regular
meetings with the ESIS director. Also at the end of
2003, the Railway Ministry issued directives to im-
plement the RNTCP in all its railway hospitals and
dispensaries.
Involving the private sector
Involvement of PPs started in zones 1 and 4 of the six
administrative zones in 2002. PPs were trained and
instructed to refer TB suspects to public microscopy
centres and act as DOT providers for patients living
close to the PP clinic. Collaboration with PPs was de-
veloped in line with RNTCP guidelines for PP involve-
ment,
11
which gave PPs free access to TB diagnosis
and drugs provided by the RNTCP.
PPs were mapped using lists produced by govern-
ment health posts and the local branch of the Indian
Medical Association (IMA) in zone 1 and by door-to-
door census in zone 4. In zone 1, PPs were reached
using a group approach. In collaboration with the
IMA, continuing medical education sessions were or-
ganised to inform PPs about the initiative. In zone 4,
project staff used a one-to-one approach to explain
the initiative and invite them to join the project. By
the third quarter of 2003, 785 of 1689 mapped PPs
(46%) had become actively involved in zone 4, com-
pared to 13% of PPs in zone 1. The difference was be-
lieved to be due to differences in sensitisation ap-
proaches. Given the greater participation in zone 4,
from the third quarter of 2003 the one-to-one approach
was also applied throughout zone 1, and the propor-
tion of listed PPs actively participating increased to
24% that quarter.
None of the small private hospitals/nursing homes
are yet linked to the RNTCP. Thus private sector in-
volvement is still limited to a fraction of private facil-
ities in two of the six zones.
Involving NGOs
The RNTCP now has formal collaboration with 45
partner NGOs, some of which have helped to create
an NGO forum, which serves as a platform for dis-
cussion and debate of problems and for identifying
ways of working with the RNTCP. They also help to
support high-risk TB patients such as pavement
dwellers, drug addicts and human immunodeficiency
virus (HIV) positive patients by arranging DOT pro-
viders, providing nutritional and financial support
and counselling the patients.
Data collection and analysis of referrals
and case notification
Standard RNTCP recording and reporting forms and
routines were introduced in all participating PPM
DOTS health facilities. The standard laboratory reg-
ister was used to note the source of referral of patients
attending the microscopy centres.
17
Referral letters
and forms to be used when providing feedback to the
referring facility were designed. The type of DOT pro-
vider was noted in the TB register. These adaptations
allowed enumeration of referrals from different pro-
vider types and disaggregation of treatment outcome
for place of treatment. Historical data on RNTCP
case notification from 1999 onwards were combined
with prospective data from the start of the interven-
tion; a time series of case notification was created to
assess whether the PPM DOTS initiative was associ-
ated with a shift in the case notification trend. This
analysis was done for the whole of Mumbai, as the
catchment population for many of the targeted pro-
viders was not limited to the administrative zones,
and the presence of large institutions in some zones,
such as the medical colleges, the TB hospital and large
NGOs, made the zones non-comparable. It was thus
not possible to establish suitable non-intervention con-
trol zones. Not all patients were treated in the place
from which they had been referred, and the number
of patients evaluated in the cohort analysis is there-
fore considerably smaller than the number of patients
referred for each non-RNTCP provider category.
RESULTS
Besides the medical colleges, the TB hospital and the
NGOs, by the fourth quarter of 2003 a total of 1018
PPs in zones 1 and 4 had become actively involved by
referring suspects, while 187 had acted as DOT pro-
viders. Of the PPs involved, 479 practised allopathic
and 539 other medical systems.
Figure 1 New smear-positive case detection under DOTS by
referring/diagnosing provider type, Mumbai 1999–2003. TB
tuberculosis; DOT directly observed treatment; NGO non-
governmental organisation; Med medical; PP private provider;
RNTCP Revised National Tuberculosis Control Programme.
PPM DOTS in Mumbai 565
In 2003, 24 620 TB cases were registered under
DOTS in Mumbai, of which 7542 (31%) were new
smear-positive cases. Of the new smear-positive cases,
5397 (72%) were self referred to the RNTCP, 509
(6.7%) were detected in the TB hospital and 485
(6.4%) in medical colleges, while PPs and NGOs had
referred respectively 614 (8.1%) and 537 (7.1%) cases.
Of the total 1733 cases diagnosed through referral by
PPs in 2003, 614 (35%) were new smear-positive cases.
There was an increase in the case notification trend
after the intervention (Figure 1). While quarterly no-
tified cases recorded as self-referrals to RNTCP facil-
ities remained relatively stable after the intervention,
the number of cases notified by the different PPM
DOTS providers increased gradually, and their total
contribution corresponded roughly to the increase in
case notification in Mumbai.
The number of suspects referred by PPs in zones 1
and 4 increased over time (Figure 2). The proportion
of those referred who were fully investigated and di-
agnosed as TB was stable, at around 60% and 40%,
respectively, throughout the study period. Almost all
of those diagnosed cases were put on DOT. The num-
ber of new smear-positive cases diagnosed through PP
referral was higher in zone 4 than in zone 1 (Figure 3).
Trend of change in case detection for all TB cases was
similar to the trend for new smear-positive cases, and
this was the case both in the whole of Mumbai as well
as in zones 1 and 4 (data not shown).
Standard RNTCP regimens were used for all regis-
tered cases regardless of DOT provider. The treat-
ment outcome for cases receiving DOT by different
provider type is shown in Table 2.
DISCUSSION
The involvement of a wide range of health care pro-
viders in different DOTS tasks was associated with an
increase in case notification, with maintained treat-
ment success. Already in 2001, the case notification in
Mumbai was 42 new smear-positive cases per 100 000,
considerably higher than the average for India in
2001 (25/100 000). The rate was 56% of national es-
timated incidence of new smear-positive TB cases in
2001 (75/100 000). In 2003, the case notification for
new smear-positive cases under DOTS increased to
61/100 000, or 81% of the national estimated inci-
dence. This indicates that the case detection rate can
be increased beyond the 70% target using the PPM
approach. However, different incidence estimates for
India have been reported in recent years. In 2001,
whereas RNTCP cited 75/100 000, the WHO cited
122/100 000;
18
in 2002, however, the WHO changed
to 75/100 000.
1
Recent tuberculin surveys have never-
Figure 2 Trend of PP referrals in zones 1 and 4. PP private
provider; RNTCP Revised National Tuberculosis Control Pro-
gramme; TB tuberculosis; DOT directly observed treatment;
Q quarter.
Figure 3 Trend of case detection of new smear-positive cases
through referral from PPs in zones 1 and 4. PP private provider;
Q quarter.
Table 2 Treatment outcome for new smear-positive cases in 2002 cohorts, by provider type*
RNTCP
n (%)
PPs
n (%)
Medical
colleges
n (%)
NGOs
n (%)
TB
hospital
n (%)
Cured 6067 (85) 181 (61) 43 (88) 249 (91) 131 (73)
Treatment completed 0 (0) 58 (20) 0 (0) 0 (0) 0 (0)
Died 352 (5) 7 (2) 0 (0) 4 (1) 29 (16)
Failure 307 (4) 15 (5) 5 (10) 10 (4) 7 (4)
Defaulter 390 (5) 35 (12) 1 (2) 12 (4) 13 (7)
Transfer out 1 (0) 0 (0) 0 (0) 0 (0) 0 (0)
Total registrations 7117 (100) 296 (100) 49 (100) 275 (100) 180 (100)
* Only cases that received treatment from PPs, NGOs, medical colleges and TB hospital are included in the respective
cohorts. Cases referred by these providers but who received treatment in RNTCP facilities are included in the RNTCP
cohort.
RNTCP Revised National Tuberculosis Control Programme; PP private provider; NGO non-governmental orga-
nisation; TB tuberculosis.
566 The International Journal of Tuberculosis and Lung Disease
theless indicated an ARTI in urban areas in Western
India of about 2.4%,
19
which roughly corresponds to
an incidence of smear-positive TB of 120/100 000.
20
Based on this estimate, the current case detection rate
would be only about 50%. To close this gap further,
continued efforts are needed to involve all health care
providers in RNTCP implementation.
In 2003, case notification of new smear-positive
cases due to referral or diagnosis through non-RNTCP
facilities represented an increment of about 40% above
the cases detected through self-referral in RNTCP
facilities. This is no proof that the increase in the gen-
eral trend can be attributed to the intervention, as this
study did not control for trend in areas with no inter-
vention. Nevertheless, the data strongly suggest that a
broad approach to utilising the existing PPM of
health care delivery is an effective way to increase case
notification. This is in agreement with evaluations of
several other PPM initiatives, which have shown sub-
stantial increases in TB case notification after apply-
ing similar strategies to involve for-profit and not-for-
profit PPs.
21–23
Although these results are encouraging,
further studies are needed, especially on the impact of
comprehensive approaches to involve all public and
private providers in DOTS delivery. There is also a
need to further improve the use of sputum smear mi-
croscopy for treatment evaluation of sputum-positive
cases and to reduce default rates among patients
treated by PPs.
It should be emphasised that the intervention in
Mumbai has not yet peaked and numerous health
care providers are not yet involved: many large and
small private hospitals are yet to be approached; pub-
lic sector providers under ESIS and the Ministry of
Railways have only just become involved, and their
contribution is yet to be measured; and only a frac-
tion of all PPs in two of six zones have been involved.
Furthermore, about 40% of all TB suspects referred
by PPs were not fully investigated. In a small follow-
up survey with household interviews of 397 such pa-
tients (unpublished data), 138 (35%) could not be
traced; among the 259 traced patients, the most com-
mon primary reasons for not completing the diagnos-
tic process was that the patient felt better or did not
feel a need for the suggested service (178/259, 68.7%),
or that the patient had returned home to a village out-
side Mumbai (53/259, 20.5%). Only 17/259 (6.5%)
said that they preferred non-DOTS treatment with
prescribed drugs in the private sector. None mentioned
financial barrier as a main reason. These findings sug-
gest that improved information for patients at the time
of referral, and improved referral chains with provid-
ers outside Mumbai, could reduce this type of default.
Some lessons on how to initiate collaboration with
private and public providers might be identified in this
study. It seems important to involve all relevant stake-
holders in the planning of TB control. In Mumbai,
this was done through the MDTCS to create an ap-
propriate collaborative environment and a sense of
ownership among public and private health providers
and departments. Previous research has shown that it
is essential to create a good collaborative environ-
ment and invest sufficient time for local stakeholder
dialogue.
24
However, to obtain clear commitment from
some public sector providers outside the MOH, who
were initially very reluctant to collaborate, clear in-
structions and regulatory interventions were needed
from the central level. For example, involvement of
medical colleges required intervention from the De-
partment of Medical Education and Research; the TB
hospital became fully involved only when procure-
ment of anti-tuberculosis drugs by the TB hospital was
replaced by drug distribution through the RNTCP;
involvement of the ESIS started on order of the Min-
istry of Labour; and the Railway health services be-
came involved after instruction from the Ministry of
Railways.
Given the common initial distrust between PPs and
NTPs, involvement of PPs needs communication to
build trust.
22,24
The public sector must be able to dem-
onstrate high technical and service quality to attract
the interest of both PPs and their patients.
22–24
Like-
wise, the PPs must demonstrate that they are capable
of managing TB according to DOTS principles to
gain trust among public sector staff. These challenges
were encountered in Mumbai, and considerable time
and resources were invested in building trust between
the RNTCP and PPs, facilitated by NGOs acting as
intermediaries. Other roles of NGOs included providing
specific input in their area of expertise, such as infor-
mation and communication, counselling and motiva-
tion of patients. For PPs, the extent of interaction at
the individual level might be more important than in the
public sector: a one-to-one approach for initial sensi-
tisation was associated with higher participation rate.
These observations indicate a need for strong coor-
dination at central level for the involvement of all rel-
evant public sector providers, while a direct, individ-
ualised approach may be more important for involving
the private sector, which is often heterogeneous, less
organised than the public sector and consists of inde-
pendently operating PPs.
Acknowledgements
This study was funded by the Stop TB Department, World Health
Organization. The authors would like to thank the staff of the Pub-
lic Health Department of the Municipal Corporation of Greater
Mumbai, all PPM project staff and all participating practitioners
and patients. We gratefully acknowledge support from Dr L S
Chauhan, Dr Leopold Blanc and Dr Mario Raviglione.
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RÉSUMÉ
CONTEXTE : Mumbai, Inde.
OBJECTIFS : Evaluer l’impact d’une approche combinée
publique-privée sur la déclaration des cas et les résultats du
traitement lorsque la lutte antituberculeuse implique des
pourvoyeurs de soins privés, des organisations non gover-
nementales (ONG) et des pourvoyeurs publics qui n’avaient
pas été impliqués antérieurement dans le Programme Na-
tional Révisé de Lutte Contre la Tuberculose (RNTCP).
METHODES : Sous la conduite du RNTCP, les pour-
voyeurs se sont vu attribuer des rôles différents dans le
transfert, le diagnostic, la mise en route du traitement,
l’exécution du DOTS, la formation et la supervision. Les
formulaires de référence ont été introduits et les registres
du RNTCP ont été adaptés pour permettre la surveillance
de la déclaration des cas par différents pourvoyeurs
ainsi que l’analyse des cohortes stratifiées selon le type
de pourvoyeur.
RESULTATS : Une fraction de l’ensemble des pourvoyeurs
hors RNTCP a été impliquée activement à la fin de 2003.
Ces pourvoyeurs ont contribué à 2.145 nouveaux cas à
bacilloscopie positive en 2003, une augmentation de 40%
en plus des 5.397 cas détectés dans les services du RNTCP.
Le taux de succès du traitement pour les cohortes de
nouveaux cas à bacilloscopie positive en 2002 a été de
85% dans les services RNTCP, de 81% dans les cli-
niques privées, de 88% dans les écoles de médecine, de
91% dans les ONG et de 73% à l’hôpital TB (où le taux
de mortalité a été de 16%).
CONCLUSION : Une implication active de certains pour-
voyeurs-clé du domaine public et privé peut augmenter
de manière substantielle la déclaration des cas tout en
maintenant des résultats acceptables du traitement. On
peut s’attendre à un impact encore plus grand lorsque la
totalité des pourvoyeurs de santé aura été impliquée.
RESUMEN
MARCO DE REFERENCIA : Mumbai, India.
OBJETIVOS : Evaluar el impacto que tendría sobre la de-
claración de los casos y el desenlace del tratamiento, la
aplicación de un programa mixto de los sectores público
y privado en la lucha contra la tuberculosis (TB), que in-
volucre proveedores privados de servicios, organiza-
ciones no gubernamentales (ONG) y proveedores públi-
cos de servicios sanitarios, no implicados previamente
en el Programa Nacional Revisado de Control de la
Tuberculosis (RNTCP).
MÉTODOS : Bajo la responsabilidad del RNTCP, se asig-
naron diferentes funciones a los proveedores de asistencia
568 The International Journal of Tuberculosis and Lung Disease
sanitaria, en la remisión, el diagnóstico, el comienzo
del tratamiento, el suministro del DOT, el adiestramiento
y la supervisión. Se introdujeron los formularios de re-
misión y se adaptaron los registros del RNTCP para per-
mitir la vigilancia de la notificación de los casos de los
diferentes proveedores y el análisis de cohortes, discrimi-
nadas según el tipo de proveedor.
RESULTADOS : Al final de 2003, una parte de los pro-
veedores externos al RNTCP estaba vinculada activa-
mente con el programa. Estos proveedores contribuye-
ron con 2145 casos nuevos con baciloscopia positiva en
2003, un incremento del 40%, además de los 5397 casos
detectados en los centros del RNTCP. En 2002, la tasa de
éxito del tratamiento en las cohortes de casos nuevos con
baciloscopia positiva fue del 85% en los centros del
RNTCP, del 81% en los consultorios privados, del 88% en
hospitales universitarios, del 91% en las ONG y del 73%
en el hospital de TB (cuya tasa de mortalidad fue del 16%).
CONCLUSIÓN : La vinculación activa de proveedores per-
tinentes del sector público y privado puede aumentar
considerablemente la declaración de casos, conservando
resultados aceptables del tratamiento. El impacto puede
ser aún mayor cuando se vincule la totalidad de los pro-
veedores de atención sanitaria.
