TB remains one of the world’s top health challenges. Nine million new TB cases emerge annually and nearly 1.5 million people die each year as a result of the disease. TB is curable but our current efforts to find, treat, and cure those ill with the disease are insufficient. Of the nine million who contract TB annually, a third of them are ‘missed’ by public health systems.

This unfortunate tendency is the theme of the 2015 World TB day message: ‘Reach the 3 Million: Reach, Treat, Cure, Everyone’.

Six thousand missing

In Nepal, the National Tuberculosis Centre’s (NTC) coming year’s objective is to find the ‘missing 6,000’ cases. The World Health Organisation (WHO)-estimated number of TB patients in the country stands at 43,000 annually. However, only 37,025 patients are being treated and the rest have not come into contact with health authorities due to a lack of access, misdiagnosis, or un-notified cases in the private sector.

Many of these missing cases are from some of Nepal’s poorest, most vulnerable communities in major urban areas. Rapid urbanisation has brought about the development of a large class of urban poor who live in slums or in overcrowded houses. Meanwhile, in remote and rural areas, many are lacking access to basic health services.

Historically, Nepal has been a leader in the region in the fight to eliminate TB. Nepal was the first country in Asia to introduce the internationally-recommended Direct Observed Treatment Short-Course (DOTS) strategy for which the country now has 100 percent coverage in primary health care centres and health posts in the country. Further, Nepal was one of the first countries globally to introduce ambulatory multidrug-resistant tuberculosis case management and has expanded this programme to all five regions of the country.

In the past few years, Nepal has consistently achieved—and surpassed—global targets for TB control of case finding (70 percent) and treatment success rate (85 percent), achieving 73 and 90 percent respectively. In achieving these targets, however, there are fears that Nepal has captured low-hanging fruit and left hard-to-reach cases on the tree.

In November 2014, an epidemiological appraisal took place to better understand the real burden of the disease and the possible reasons for missing cases. A number of national staff underwent WHO training in Indonesia and now, in collaboration with RIT Japan, will be undertaking the country’s first prevalence survey later this year. With the results of the study not expected for at least 18 months from the study’s commencement date, what can be done concurrently to reach the seemingly unreachable?

Public-private approach

As one of the world’s most geographically and culturally diverse countries, Nepal cannot apply a one-size-fits-all approach in attempting to reach the remaining fruit on the tree. One of the key problems related to this is the inadequacy of service coverage. Some excellent specialised service systems of care are available for the diagnosis of more complicated cases of TB in some districts, but not in others. Often, it is the more remote and mountainous regions that are not covered. On occasions, there are difficulties in making referrals from the district health care system to the specialist system, resulting in access and equity disparities.

With the private sector running parallel to the public system—and at times being poorly integrated—Nepal has the opportunity to extend coverage by engaging all TB care providers through a public-private mix (PPM) approach that improves coordination between the sectors.

The private sector in Nepal is vast and heterogeneous, consisting of a wide variety of players that are directly or indirectly involved in the provision of healthcare services. Whilst the NTC has sought to expand PPM to 58 different areas since its implementation in 2006, there has been some inertia in carving out long-term sustainable partnerships.

With approximately 23.1 percent of TB cases held by the private sector and only eight percent of all notified cases reported by private providers and NGOs, there are many benefits of engaging in more aggressive PPM activities. External development partners, INGOs, NGOs, and the profit-oriented private sector all play an important role in Nepal’s health system. Effective partnerships between these parties have been critical to Nepal’s path to achieving the Millennium Development Goals and its increased ability to provide access to basic health services for women, children, the impoverished and marginalised.

Increased engagement of these players in TB control and lung health more generally will result in harmonisation of TB management, improved treatment outcomes, and increased case detection. As Nepal seeks to reach past the low hanging fruit with the NTC guiding the ladder into place, a strong PPM programme will shore-up the rungs for a steady climb to success.

Sarah Korver is a public health researcher and Australian Volunteer for International Development  (AVID) working as an Urban Health Officer at the National Tuberculosis Centre, Nepal.  The AVID programme is an Australian Government initiative.