Management of Tuberculosis by Public and Private Health Care Providers in Laukkai Township, China Border Area, Northern Shan State, Myanmar

Thida, Saw Saw,Thandar Lwin, KyawKoKo Htet, NweNwe Kyaw, PhyuPhyu Khaing& KyawZin Thant

Special Issue May 2020

Tuberculosis (TB) management in Myanmar China border, a high TB burden area, was a knowledge gap. A cross-sectional mixed-methods study was conducted in hard-to-reach high TB burden Laukkai Township, Northern Shan State during 2012 and 2013. It was aimed to identify management of TB among public and private health care providers in the study area. A total of 14 Basic Health Staff (BHSs) who had involved in TB management and 37 private providers (34 General Practitioners (GPs) and 3 providers from Asia Harm Reduction Network (AHRN)) were included in the study. Majority of the GPs (67.7%) were Chinese speaking providers. The overall knowledge score on TB management was significantly lower among GPs (14.0±10.2) than that of BHS (30±6.5). Records keeping, availability of referral forms, patient record books, treatment cards and TB information, education and communication materials were almost not available at GPs. Providers from AHRN followed the NTP guidelines in the management of TB. Diagnosis and treatments of TB by GPs was not in line with NTP guidelines. However, GPs were perceived as important partners in TB control. GPs were also willing to collaborate with NTP. In conclusion, management of TB among GPs in Laukkai Township was not in line with NTP guidelines and providing them the updated TB management information in local language will be helpful. Close collaboration between public and private providers could provide better TB management in Laukkai Township

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Tuberculosis (TB) is a major public health problem in Myanmar. Myanmar is one of 30 countries for TB/HIV-TB and MDR-TB.¹ According to 2009-2010 nationwide pre-valence survey, the observed prevalence of smear-positive TB was higher than the previous WHO estimation.^{2, 3}Engaging all health care providers in TB control is one of the strategies and implementation approaches in the End TB Strategy. National Tuberculosis Programme (NTP) started piloting linkages with private providers since the late 1990s to improve Case Detection Rate (CDR) and Cure Rate (CR). In Laukkai Township, no TB team was available at the time of the study. Basic Health Staff (BHSs) of the District Hospital were taking care of the TB patients and there were many non-Bamar language speaking Chinese General Practitioners (GPs). Asia Harm Reduction Network (AHRN), an International Non-Governmental Organization, implemented a TB management there in collaboration with NTP. TB management at Laukkai District Health System and availability of private clinics for TB management has no many changes until recently. There had been no study conducted previously on the health care providers about their background information and how they were managing TB patients. According to the previous study, current practices of private practitioners on TB patients were not in line with NTP guidelines.^{4, 5} NTP needs to know the situation of TB management among public and private health care providers in hard-to-reach areas in order to get the nation-wide information for effective TB control. This collaborative study among NTP and Departments of Medical Research aimed to find out not only the management of TB by different health care providers but also aimed to elicit their knowledge on TB management, current practices, problems encountered on TB management and opinion and suggestions to improve cooperation among public and private health care providers in TB control. Thus, findings from this study will be very crucial for NTP in both current and future implementation of TB control in terms of achieving the targeted CDR, CR and Treatment Success Rate (TSR) in hard-to-reach areas.

Study design

This was a community-based, cross-sectional descriptive study using both quantitative and qualitative data collection methods.

Study area

Laukkai Township was purposively selected with high TB cases but unsatisfactory treatment outcomes of low CR and TSR  in 2009-2010 cohorts to understand TB management in China boarder area of Northern Shan State.

Study population, sample size and study period

Public and private health care providers including District Medical Officers (DMOs), all BHSs of Laukkai District Health Department (DHD) who were engaged with TB management and private practitioners (GPs) were the study population. A total of 14 public and 37 GPs and INGO staff participated in the study during August 2012 and August 2013.

Data collection methods

Face-to- face interview

All GPs were approached at their clinics. Face-to-face interview explored the participants’ background characteristics, know-ledge of TB signs and symptoms, mode of transmission, diagnosis, and treatment and follow-up, exposure on the job of TB management training provided by NTP, diagnosis of TB, referring symptomatic patients, provision of treatment and follow-up of TB patients. The interview was done by the principal investigator by using pre-tested semi-structure questionnaire in local language. The principal investigator was a local language speaker and no interpretation was needed throughout the interviews.

Self-administered questionnaire

BHSs were approached at Township Health Department (THD). They were requested to participate answering self-administered questionnaire. All the questionnaires were read and explained by the Principal Investigator (PI) till they all understand before starting answering. Similar questionnaires of GPs were used for BHSs except assessing knowledge on categorizing TB patients because they had no responsibility to do such task.  The questionnaires were developed with references to the manual for BHS on TB management, 2009.

In-depth interview

Participants selected for in-depth interview (IDI) were approached by investigators after getting voluntary informed consent. Ten IDIs were conducted with 3 BHSs, 4 GPs and
3 Medical Officers from AHRN. Bamar language was used while interviewing with BHS and Kokang language were used with non-Bamar speaking GPs and interpretation was not needed.

Record reviewing

TB registers and treatments cards of 2012 from Township Health Department, AHRNand GPs were reviewed for the identification of the recording and referral systems with permission of LaukkaiDistric Health Officer and responsible officer of AHRN, Laukkai.

Observation

Observation of the presence of health educating materials (poster for pamphlets), presence of patient register, referral form, feedback form, TB patient register, treatment card, presence of anti-tuberculosis drugs and weighing machine were done during data collection with checklist at private clinics.

Data management, quality control and data analysis

Data were checked for completeness and relevancy at the field and it was entered into computer system by using EpiData 3.02. Data cleaning and recoding was done and the cleaned data was analysed by using SPSS software version 20.

Background characteristics, types of private providers, exposure on TB management training from NTP, record keeping, diagnosis of TB, referring symptomatic patients, provision of treatment and follow-up of TB patients were described descriptively. Chi- square test or Fisher Exact test was used for comparison of categorical data. Mean knowledge score on TB, diagnosis and treatment, and monitoring of the patients was compared among different health care providers and t test was used for comparison. Critical level of significance was set at p-value <0.05.

Scoring of knowledge

It was given as score "1" for correct response and "0" of incorrect response. Total knowledge score was obtained by summing up the knowledge scores of general knowledge on TB, TB diagnosis and treatment and monitoring of TB patients.Mean knowledge scores were compared among different health care providers.

Qualitative data

Tape-recorded qualitative information was fully transcribed in Myanmar language and analysed by using Atlas ti 5.2. Thematic analysis was done to achieve the objectives. All transcripts were read several times by the investigators separately to bring out the main ideas. Then discussions among investigators on the most prevalent expressions for each theme and sub-theme were done and quotations were taken with the agreements by the majority of the investigators.

Ethical consideration

Ethical approval was obtained from the Ethical Review Committee of Department of Medical Research (Upper Myanmar).



The findings from the current study showed that TB patients in Laukkai sought care mainly from GPs followed by international non-governmental organization and public sector. Majority of the GPs who did not speak Myanmar language had never received TB training provided by NTP. The overall TB knowledge of GP was low and their TB management was not in line with NTP guidelines. There is a need to establish cooperation between public and private providers, especially with the GPs and different perceptions were observed for involving GPs in TB control at the local area.

Private GPs had a substantial contribution in TB management in Myanmar. An inter-vention study involving private GPs in TB control conducted in Kyaukse, Mandalay Region showed that private GPs contributed 44% of new smear-positive cases registered during the study period (July 2002-December 2004). The notification of new sputum smear-positive TB in the study area increased by 85% between the year prior to the GP involvement and 2 years after. Case notification increased by 57% in the control townships and by 42% in all of Mandalay Division. The treatment success rate for new smear-positive cases treated by GPs was over 90%.⁶An increasing trend of the private GP’s contribution was consistently found in the period of 2007 to 2014. It increased from 11% in 2007 to 18% in 2014.⁷Some patients sought treatment round and round at GPs before reaching public health sector.⁸

In addition to the private GPs, international organizations are widely participating in TB control in hard-to-reach border areas and active case finding and case holding by INGO is well-known worldwide including Myanmar.⁹ Similarly, the findings of the current study showed that GPs and INGO clinic play an important role in TB management in Laukkai.

Close cooperation between public and private healthcare services was suggested to be effective at identifying and treating active TB cases.¹⁰ Available TB management by public and private providers in Laukkai has not changed until recently and with the study findings of high case holding by private GPs, presence of mismanagement of TB indicates ensuring private GPs’ management of TB to be in line with the NTP guidelines is required. This can prevent undue delay in diagnosis and treatment of TB symptomatic cases and it in turns can reduce poor TB treatment outcome.¹¹ Stakeholders collaboration in TB management was limited in border area of Myanmar. Unstructured information sharing and lack of communication hindered the stakeholders from engaging in TB control. Other challenges were increasing loss to follow-up, constraints of service delivery, shortage of human resources, limited staff capacities within organizations and poor socioeconomic status of patients. It was recommended to strengthen the referral mechanisms across the border.¹² Similar finding was found in the current study which supported the previous study on recommend-dation of collaboration between the stake-holders of TB care.

The study explored the management of TB management in Laukkai Township that is hard-to-reach in terms of language, sociocultural barriers and lack of knowledge among TB patients. The principal investi-gator spoke the same language as the local GPs and there was not need translation and it prevented from incorrect interpretation and had a good rapport with the non-Bamar language speaking GPs. However, there are limitations such as no representatives GPs residing outside the Laukkai downtown area. This can undermine the findings of the study. TB management from the perspectives of patients could not be revealed although it is an important perspective to have a comprehensive overview of TB management. In addition, TB healthcare system at the local area is important in addition to the TB patients’ and providers’ perspectives. Thus, further study that includes the perspectives of health system and that of the patients to have a comprehensive TB management in the specific area is recommended.

Conclusion and recommendation

In conclusion, management of TB was not in line with NTP guideline among GPs in hard-to-reach Laukkai Township. Private GPs were perceived as important partners for TB control and updated TB information in local language and training on TB management was requested. Close cooperation between public and private GPs by providing updated TB management guidelines in local language is urgently needed to reduce the mismanagement of GPs in TB management. Effective-ness of involving GPs in referral of TB symptomatic patients in Laukkai Township can be further explored.

The authors declare that they have no competing interests.

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