RESUMEN
Nigeria has a high burden of tuberculosis (TB) and low case detection rates. Nigeria's large private health sector footprint represents an untapped resource for combating the disease. To examine the quality of private sector contributions to TB, the USAID-funded Sustaining Health Outcomes through the Private Sector (SHOPS) Plus program evaluated adherence to national standards for management of presumptive and confirmed TB among the clinical facilities, laboratories, pharmacies, and drug shops it trained to deliver TB services. The study used a standardized patient (SP) survey methodology to measure case management protocol adherence among 837 private and 206 public providers in urban Lagos and Kano. It examined two different scenarios: a "textbook" case of presumptive TB and a treatment initiation case where SPs presented as referred patients with confirmed TB diagnoses. Private sector results were benchmarked against public sector results. A bottleneck analysis examined protocol adherence departures at key points along the case management sequence that providers were trained to follow. Except for laboratories, few providers met the criteria for fully correct management of presumptive TB, though more than 70% of providers correctly engaged in TB screening. In the treatment initiation case 18% of clinical providers demonstrated fully correct case management. Private and public providers' adherence was not significantly different. Bottleneck analysis revealed that the most common deviations from correct management were failure to initiate sputum collection for presumptive patients and failure to conduct sufficiently thorough treatment initiation counseling for confirmed patients. This study found the quality of private providers' TB case management to be comparable to public providers in Nigeria, as well as to providers in other high burden countries. Findings support continued efforts to include private providers in Nigeria's national TB program. Though most providers fell short of desired quality, the bottleneck analysis points to specific issues that TB stakeholders can feasibly address with system- and provider-level interventions.
RESUMEN
INTRODUCTION: Pneumococcal conjugate vaccines are expensive relative to those in the EPI systems of low-income countries. The current single-dose presentation costs more to store in the cold chain relative to multi-dose presentations but also has lower wastage rates. It is, therefore, important to determine the optimal balance of vial size and storage costs after adjusting for wastage. OBJECTIVES: To project the cost implications of wastage when vaccine wastage rates vary across vial sizes using country specific wastage data. RESULTS: Only 19 (26%) of 72 GAVI eligible countries had analyzable wastage data at WHO/HQ. The median wastage rates for single, 2- and 10-dose vials were 5%, 7% and 10% respectively. However wastage varied between 1%-10%, 1%-27% and 4%-44% for single, 2- and 10-dose vials respectively. The increased variance for multi-dose vial wastage implied wastage costs potentially greater than the savings realized from lower storage volumes. METHODS: For each potential vial size, we estimated cold chain costs and the cost of wasted vaccine doses using country level wastage data and projections of the price per dose of vaccine and cold chain storage. CONCLUSIONS: The optimal vial-size for PCV is dependent upon country specific wastage rates but few countries have these data. There may be a role for both single and multi-dose vials that is best determined by local management and storage capacities making local wastage data critical. Without effective wastage monitoring and control there is a risk that wastage costs will possibly exceed the savings from multi-dose vials' lower storage costs.