Financial Profit in Medicine: A Position Paper From the American College of Physicians.

The steady growth of corporate interest and influence in the health care sector over the past few decades has created a more business-oriented health care system in the United States, helping to spur for-profit and private equity investment. Proponents say that this trend makes the health care system more efficient, encourages innovation, and provides financial stability to ensure access and improve care. Critics counter that such moves favor profit over care and erode the patient-physician relationship. American College of Physicians (ACP) underscores that physicians are permitted to earn a reasonable income as long as they are fulfilling their fiduciary responsibility to provide high-quality, appropriate care within the guardrails of medical professionalism and ethics. In this position paper, ACP considers the effect of mergers, integration, private equity investment, nonprofit hospital requirements, and conversions from nonprofit to for-profit status on patients, physicians, and the health care system.

[Public, private or third sector management? Differences in the results in Primary Care in Catalonia]. / ¿Gestión pública, privada o por el tercer sector? Diferencias en los resultados en atención primaria de Cataluña.

GOAL: Compare the performance of primary health centers managed by the public sector (ICS), the third sector (Hospitals) or by small private organizations known as EBAs. DESIGN: Multidimensional comparative analysis. We follow a quasi-experimental logic comparing primary health centers managed by EBAs with other centers managed by the public sector (ICS) o by the third sector (hospitals). LOCALIZATION: Barcelona, Catalonia, Spain. PARTICIPANTS: We have 368 observations (primary health centers) and 18 indicators measured in 2015. INTERVENTION: Different management models (public, third sector, private). MAIN MEASURES: We compare activity measures, measures of effectiveness in the process of medical assistance, and efficiency. We compare before and after controlling for the socio-economic level corresponding to the basic health area and the characteristics of the population and health region. We conduct a test of significant differences between the indicators corresponding to centers managed differently, after a process of matching using key variables and Propensity Score Matching. RESULTS: Significant differences in the measure of work load for family doctors, in five measures of effectiveness in the process of assistance and in the cost per user. CONCLUSIONS: The diversity in the management model through EBAs shows results that can be interpreted in favor of the maintenance or the expansion of this model of management. The majority of EBAs have been implanted in areas of a medium or high level, but their results are still significantly positive once the socio economic level of the area is controlled.

Do public nursing home care providers deliver higher quality than private providers? Evidence from Sweden.

BACKGROUND: Swedish nursing home care has undergone a transformation, where the previous virtual public monopoly on providing such services has been replaced by a system of mixed provision. This has led to a rapidly growing share of private actors, the majority of which are large, for-profit firms. In the wake of this development, concerns have been voiced regarding the implications for care quality. In this article, we investigate the relationship between ownership and care quality in nursing homes for the elderly by comparing quality levels between public, for-profit, and non-profit nursing home care providers. We also look at a special category of for-profit providers; private equity companies. METHODS: The source of data is a national survey conducted by the Swedish National Board of Health and Welfare in 2011 at 2710 nursing homes. Data from 14 quality indicators are analyzed, including structure and process measures such as staff levels, staff competence, resident participation, and screening for pressure ulcers, nutrition status, and risk of falling. The main statistical method employed is multiple OLS regression analysis. We differentiate in the analysis between structural and processual quality measures. RESULTS: The results indicate that public nursing homes have higher quality than privately operated homes with regard to two structural quality measures: staffing levels and individual accommodation. Privately operated nursing homes, on the other hand, tend to score higher on process-based quality indicators such as medication review and screening for falls and malnutrition. No significant differences were found between different ownership categories of privately operated nursing homes. CONCLUSIONS: Ownership does appear to be related to quality outcomes in Swedish nursing home care, but the results are mixed and inconclusive. That staffing levels, which has been regarded as a key quality indicator in previous research, are higher in publicly operated homes than private is consistent with earlier findings. The fact that privately operated homes, including those operated by for-profit companies, had higher processual quality is more unexpected, given previous research. Finally, no significant quality differences were found between private ownership types, i.e. for-profit, non-profit, and private equity companies, which indicates that profit motives are less important for determining quality in Swedish nursing home care than in other countries where similar studies have been carried out.

The adequacy of antenatal care services among slum residents in Addis Ababa, Ethiopia.

BACKGROUND: There are recent efforts made to eliminate inequalities in the utilisation of basic health care services. More emphasis is given for improvement of health in developing countries including maternal and child health. However, disparities for the fast-growing population of urban poor are masked by the urban averages. The aim of this paper is to report on the findings of antenatal care adequacy among slum residents in Addis Ababa, Ethiopia. METHODS: This was a quantitative and cross-sectional community based study design which employed a stratified two-stage cluster sampling technique to determine the sample. Data was collected using structured questionnaire administered to 870 women aged 15-49 years. Weighted 'backward selection' logistic regression models were employed to identify predictors of adequacy of antenatal care. RESULTS: Majority of slum residents did not have adequate antenatal care services with only 50.3, 20.2 and 11.0 % of the slum resident women initiated antenatal care early, received adequate antenatal care service contents and had overall adequate antenatal care services respectively. Educational status and place of ANC visits were important determinant factors for adequacy of ANC in the study area. Women with secondary and above educational status were 2.7 times more likely to receive overall adequate care compared to those with no formal education. Similarly, clients of private healthcare facilities were 2.2 times respectively more likely to receive overall adequate antenatal care compared to those clients of public healthcare facilities. CONCLUSION: In order to improve ANC adequacy in the study area, the policy-making, planning, and implementation processes should address the poor adequacy of ANC among the disadvantaged groups in particular and the slum residents in general.

[Adapting a private health care facility to the new Peruvian Public Health Sistem. Quality rating in a Middle Income Economy country]. / L'adeguamento di una struttura sanitaria privata alla nuova sanità pubblica Peruviana. Valutazione di qualità in un paese a Middle Income Economy.

The aim of the study is the Assessment of Quality Sevices provided by a no-profit Medical Center in Peruvian Sierra, through an evidence-based decision-making process to identify infrastructure and capacity building interventions, to achieve accreditation and economic sustainability and increase competitiveness in the renewed Peruvian National Health System. The quali-quantitative collection of data shows how is fundamental an Healthcare Management focused on the responsiveness of services to the real needs and the local culture to reach the goals.

Assessment of facility readiness and provider preparedness for dealing with postpartum haemorrhage and pre-eclampsia/eclampsia in public and private health facilities of northern Karnataka, India: a cross-sectional study.

BACKGROUND: The maternal mortality ratio in India has been declining over the past decade, but remains unacceptably high at 212 per 100,000 live births. Postpartum haemorrhage (PPH) and pre- eclampsia/eclampsia contribute to 40% of all maternal deaths. We assessed facility readiness and provider preparedness to deal with these two maternal complications in public and private health facilities of northern Karnataka state, south India. METHODS: We undertook a cross-sectional study of 131 primary health centres (PHCs) and 148 higher referral facilities (74 public and 74 private) in eight districts of the region. Facility infrastructure and providers' knowledge related to screening and management of complications were assessed using facility checklists and test cases, respectively. We also attempted an audit of case sheets to assess provider practice in the management of complications. Chi square tests were used for comparing proportions. RESULTS: 84.5% and 62.9% of all facilities had atleast one doctor and three nurses, respectively; only 13% of higher facilities had specialists. Magnesium sulphate, the drug of choice to control convulsions in eclampsia was available in 18% of PHCs, 48% of higher public facilities and 70% of private facilities. In response to the test case on eclampsia, 54.1% and 65.1% of providers would administer anti-hypertensives and magnesium sulphate, respectively; 24% would administer oxygen and only 18% would monitor for magnesium sulphate toxicity. For the test case on PPH, only 37.7% of the providers would assess for uterine tone, and 40% correctly defined early PPH. Specialists were better informed than the other cadres, and the differences were statistically significant. We experienced generally poor response rates for audits due to non-availability and non-maintenance of case sheets. CONCLUSIONS: Addressing gaps in facility readiness and provider competencies for emergency obstetric care, alongside improving coverage of institutional deliveries, is critical to improve maternal outcomes. It is necessary to strengthen providers' clinical and problem solving skills through capacity building initiatives beyond pre-service training, such as through onsite mentoring and supportive supervision programs. This should be backed by a health systems response to streamline staffing and supply chains in order to improve the quality of emergency obstetric care.

Use of antibacterial fixed-dose combinations in the private sector in eight Latin American Countries between 1999 and 2009.

OBJECTIVE: To assesses the safety and rationale of antibacterial fixed-dose combinations in the private sector in Latin America and determine the extent of their use. METHODS: Analysis of FDCs was based on retail sales data for eight Latin American countries (Argentina, Brazil, Chile, Colombia, Mexico, Peru, Uruguay and Venezuela) between 1999 and 2009. FDCs were classified according to the pre-defined criteria. Use was expressed as daily defined doses per 1000 inhabitants per day (DDD/TID). RESULTS: A total of 175 antibacterial FDCs contained a mean of 1.3 antibacterial substances and 3.2 other active substances. Thirty-seven (21%) FDCs were classified as unsafe, 124 (70%) as lacking sufficient evidence for efficacy and only 14 (9%) of all FDCs were considered rational, for example amoxicillin and clavulanic acid. Consumption of unsafe FDCs decreased by 0.011 DDD/TID (95% CI: -0.012 to -0.009) annually, from 0.173 DDD/TID in 1999 to 0.070 DDD/TID in 2009 (overall decrease, 59.7%). Consumption of FDCs lacking sufficient evidence decreased by 30.3% (-0.018 DDD/TID [95% CI: -0.028 to -0.008] annually), while use of rational FDCs increased by 17.1% (from 1.283 DDD/TID to 1.497 DDD/TID annually). CONCLUSION: The majority of antibacterial FDCs in the private sector lack therapeutic benefit. Despite the decrease in the consumption of unsafe antibacterials and those lacking sufficient evidence, their use remains high and their marketing does not fit into strategies of prudent use of antibiotics to contain antibacterial resistance.

Public and private health care services in the opinion of physicians in Poland.

OBJECTIVES: Health care services in Poland are delivered by public and private providers. The aims of this study were to assess the attitudes towards private and public health care services in Poland and to identify differences between them, in the opinion of physicians. MATERIAL AND METHODS: A questionnaire-based survey was carried out among physicians attending mandatory courses delivered at the School of Public Health, the Centre of Postgraduate Medical Education in Warsaw, Poland. The questionnaire included 29 questions concerning private and public health care services. RESULTS: Completed questionnaires were obtained from 502 physicians (67.7% females), aged 42.1±10.8 years, with a response rate of 77.2%. In the opinion of the surveyed doctors, the major advantages of private health care units, in comparison with public ones, are short waiting times for an appointment (88.2%), an efficient on-site service (78.6%) and convenient appointment times (75.7%). The respondents gave high scores to items such as relations with patients (p < 0.001), superiors (p < 0.001) and colleagues (p = 0.03) when working in private, rather than public, institutions. In the opinion of physicians, public health care institutions guarantee better employment conditions (44.4% vs. 13%; p < 0.001) and security (29.1% vs. 11.1%; p < 0.001) than private ones. The respondents did not observe any differences (p > 0.05) between public and private facilities in terms of the involvement of medical staff and infrastructure. There were significant differences (p < 0.001) in the perception of working conditions in public and private health care institutions depending on the medical education level and the place of primary employment. CONCLUSIONS: Among physicians in Poland, private medical institutions are perceived as better organized and granting faster as well as more comprehensive access to health care services when compared to public ones. Closing the gaps between working conditions in public and private units could encourage physicians to practice in the public health care sector. Int J Occup Med Environ Health. 2020;33(2):195-214.

Breadth and Exclusivity of Hospital and Physician Networks in US Insurance Markets.

Importance: Little is known about the breadth of health care networks or the degree to which different insurers' networks overlap. Objective: To quantify network breadth and exclusivity (ie, overlap) among primary care physician (PCP), cardiology, and general acute care hospital networks for employer-based (large group and small group), individually purchased (marketplace), Medicare Advantage (MA), and Medicaid managed care (MMC) plans. Design, Setting, and Participants: This cross-sectional study included 1192 networks from Vericred. The analytic unit was the network-zip code-clinician type-market, which captured attributes of networks from the perspective of a hypothetical patient seeking access to in-network clinicians or hospitals within a 60-minute drive. Exposures: Enrollment in a private insurance plan. Main Outcomes and Measures: Percentage of in-network physicians and/or hospitals within a 60-minute drive from a hypothetical patient in a given zip code (breadth). Number of physicians and/or hospitals within each network that overlapped with other insurers' networks, expressed as a percentage of the total possible number of shared connections (exclusivity). Descriptive statistics (mean, quantiles) were produced overall and by network breadth category, as follows: extra-small (<10%), small (10%-25%), medium (25%-40%), large (40%-60%), and extra-large (>60%). Networks were analyzed by insurance type, state, and insurance, physician, and/or hospital market concentration level, as measured by the Hirschman-Herfindahl index. Results: Across all US zip code-network observations, 415 549 of 511 143 large-group PCP networks (81%) were large or extra-large compared with 138 485 of 202 702 MA (68%), 191 918 of 318 082 small-group (60%), 60 425 of 149 841 marketplace (40%), and 21 781 of 66 370 MMC (40%) networks. Large-group employer networks had broader coverage than all other network plans (mean [SD] PCP breadth: large-group employer-based plans, 57.3% [20.1]; small-group employer-based plans, 45.7% [21.4]; marketplace, 36,4% [21.2]; MMC, 32.3% [19.3]; MA, 47.4% [18.3]). MMC networks were the least exclusive (a mean [SD] overlap of 61.3% [10.5] for PCPs, 66.5% [9.8] for cardiology, and 60.2% [12.3] for hospitals). Networks were narrowest (mean [SD] breadth 42.4% [16.9]) and most exclusive (mean [SD] overlap 47.7% [23.0]) in California and broadest (79.9% [16.6]) and least exclusive (71.1% [14.6]) in Nebraska. Rising levels of insurer and market concentration were associated with broader and less exclusive networks. Markets with concentrated primary care and insurance markets had the broadest (median [interquartile range {IQR}], 75.0% [60.0%-83.1%]) and least exclusive (median [IQR], 63.7% [52.4%-73.7%]) primary care networks among large-group commercial plans, while markets with least concentration had the narrowest (median [IQR], 54.6% [46.8%-67.6%]) and most exclusive (median [IQR], 49.4% [41.9%-56.9%]) networks. Conclusions and Relevance: In this study, narrower health care networks had a relatively large degree of overlap with other networks in the same geographic area, while broader networks were associated with physician, hospital, and insurance market concentration. These results suggest that many patients could switch to a lower-cost, narrow network plan without losing in-network access to their PCP, although future research is needed to assess the implications for care quality and clinical integration across in-network health care professionals and facilities in narrow network plans.

Hospice care for patients with dementia: does volume make a difference?

Using the repository of 2005 Family Evaluation of Hospice Care data, this study examined whether bereaved family members report higher quality of care when hospices care for greater vs. lesser proportions of dementia patients. This organization-level analysis included 396 hospices meeting the study's eligibility criteria. Using hospice percentages of the "proportion of decedents with dementia," categories representing the lower three, the fourth and highest quintile values were created (i.e., <13%, > or =13%-19%, and > or =19%). Analyses were stratified by for-profit vs. not-for-profit because preliminary analyses showed differential associations by profit status. In for-profit hospices, hospices with the highest vs. lowest proportion of dementia patients (> or =19% vs. <13%) had significantly lower unmet pain needs (-1.7%, 95% confidence interval [CI] -3.1%, -0.2%). However, for both profit groups, caring for > or =19% dementia decedents (vs. <13%) was associated with a lower proportion of "excellent" care ratings (-2.3%, 95% CI -4.5%, -0.2%). Statistically significant associations between higher volume and better ratings were not observed for the remaining (six) outcomes, although this trend was found more among for-profit hospices. Thus, profit status appears to modify the association between volume of dementia care and care ratings. Further study is needed to understand the nonintuitive negative association between higher volume and lower satisfaction. This study emphasizes the need for examination of quality outcomes by profit status.

Managerial Ownership in Nursing Homes: Staffing, Quality, and Financial Performance.

Purpose of the Study: Ownership of nursing homes (NHs) has primarily focused broadly on differences between for-profit (FP), nonprofit (NFP), and government-operated facilities. Yet, among FPs, the understanding of detailed ownership structures at individual NHs is rather limited. Particularly, NH administrators may hold significant equity interests in their facilities, leading to heterogeneous financial incentives and NH outcomes. Through the principal-agent theory, this article studies how managerial ownership of individual facilities affects NH outcomes. Design and Methods: We use a unique panel dataset of Ohio NHs (2005-2010) to empirically examine the relationship between managerial equity ownership and NH staffing, quality, and financial performance. We identify facility administrators as owner-managers if they have more than 5% of the equity stakes or are relatives of the owners. The statistical analysis is based on the pooled ordinary least squares and NH-fixed effect models. Results: We find that owner-managed NHs are associated with higher nursing staff levels compared to other FP NHs. Surprisingly, despite higher staffing levels, owner-managed NHs are not associated with better quality and we find no statistically significant difference in financial performance between owner-managed and nonowner-managed FP NHs. Our results do not support the principal-agent model and we offer alternative explanations for future research. Implications: Our findings provide empirical evidence that NH ownership structures are more nuanced than simply broadly categorizing facilities as FP or NFP, and our results do not fully align with the standard principal-agent model. The role of managerial ownership should be considered in future NH research and policy discussions.

A randomized controlled trial of Minnesota day clinic treatment of alcoholics.

AIM: To compare the Minnesota day clinic treatment with the traditional public psychosocial treatment. DESIGN: Randomized controlled trial. SETTING: Public out-patient alcohol clinic and privately funded Minnesota day clinic in Denmark. PARTICIPANTS: A total of 148 individuals with alcohol dependence were included in a 1-year clinical trial. MEASUREMENTS: Self-reported drinking pattern and the seven composite scores from the addiction severity index (ASI). FINDINGS: A total of 42 (57%) and 45 (61%) patients (P > 0.05) completed the Minnesota treatment and public treatment, respectively. Throughout the whole 12-month follow-up period, 35% of the patients treated at the Minnesota day clinic were abstainers, while this was the case for 20% of the patients treated in the public out-patient alcohol clinic (P = 0.043). During the last month before the end of the 1-year follow-up, 53% of the patients treated according to the Minnesota model were abstainers, while this was the case for 43% of the patients treated in the public out-patient alcohol clinic (P = 0.249). There were insignificant differences in the seven ASI scores. CONCLUSIONS: Twelve months after onset of treatment, the Minnesota day clinic treatment does not differ in effect from the much cheaper 'standard' public treatment. However, patients in Minnesota treatment were total abstainers throughout a longer period.

Assessment of quality guidelines implementation using a continuous quality improvement programme.

BACKGROUND: Data from the Dialysis Outcomes and Practice Patterns Study (DOPPS) study suggest that the level of implementation of the European Best Practice Guidelines (EBPG) is at best partial. The main aim of this study is to describe the level of implementation of the EBPG in the European Fresenius Medical Care (FME) clinic network. METHODS: Data presented in this investigation were gained through the FME database EuCliD (European Clinical Database). Patient data from 4 countries (Great Britain, France, Italy, Spain) were selected from the EuCliD database. The parameters chosen were haemodialysis adequacy, biocompatibility, anaemia control and serum phosphate control, which are surrogate indicators for quality of care. They were compared, by country, between the first quarter (Q1) 2002 and the fourth quarter (Q4) 2005. RESULTS: During Q1 2002 and Q4 2005, respectively, a total of 7,067 and 9,232 patients were treated in FME clinics located in France, Italy, Spain and the UK. This study confirms variations in haemodialysis practices between countries as already described by the DOPPS study. A large proportion of patients in each country achieved the targets recommended by the EBPG in Q4 2005 and this represented a significant improvement over the results achieved in Q1 2002. CONCLUSIONS: Differences in practices between countries still exist. The FME CQI programme allows some of these differences to be overcome leading to an improvement in the quality of the treatment delivered.

Capacity strengthening in malaria research: the Gates Malaria Partnership.

The Gates Malaria Partnership (GMP) includes five African and four European partner institutions. Its research programme has five priority areas involving an extensive range of field-based studies. GMP research has contributed significantly to the development of new research consortia investigating strategies for improving means of malaria control, and has already had an impact on policy and practice. A substantial investment in innovative training activities in malaria has enhanced knowledge and practice of malaria control at all levels from policy making to local community involvement. Capacity development, notably through a PhD programme, has been an underlying feature of all aspects of the programme.

Database-supported teleconferencing: an additional clinical mentoring tool to assist a multinational company HIV/AIDS treatment program in Africa.

BACKGROUND: The lack of human resources for health is presently recognized as a major factor limiting scale-up of antiretroviral treatment (ART) programs in resourcelimited settings. The mobilization of public and private partners, the decentralization of care, and the training of non-HIV specialist nurses and general practitioners could help increase the number of HIV-infected patients receiving ART. In addition to other forms of training, scheduled teleconferences (TCs) have been organized to support a comprehensive HIV treatment program delivered by a private company's health team. OBJECTIVE: To describe the role of the TC as an additional tool in mentoring a company's health care workers (HCWs). METHOD: For this study, all TC reports were retrospectively reviewed and the questions classified by topic. Participating Heineken physicians evaluated the technical quality and scientific relevance of the TCs through an anonymous survey. RESULTS: From October 2001 to December 2003, 10 HCWs working in 14 operating companies in 5 African countries raised 268 problems during 45 TCs. A total of 79 questions (29%) were asked about antiretroviral (ARV) therapy, 53 (20%) about the diagnosis and treatment of opportunistic infection, 43 (16%) about ARV toxicity, 40 (15%) about care organization and policy, 32 (12%) about laboratory or drug supply, and 21 (8%) about biological parameters. The mean TC attendance rate was 70%. The level of satisfaction among local company physicians was 65% for logistics, 89% for scientific relevance, 84% for applicability of advice, and 85% overall. The most common complaints concerned the poor quality of the telephone connection and language problems for francophone participants. CONCLUSION: Database-supported teleconferencing could be an additional tool to mentor company HCWs in their routine care of HIV-infected workers and family members. The role and costeffectiveness of telemedicine in improving health outcomes should be further studied.

[Individual health services without compensation claims from the private health insurances' perspective]. / Individuelle Gesundheits- leistungen ohne Anspruch auf Erstattung aus der Sicht eines privaten Krankenversicherers.

Health insurance should provide medically indicated treatment for everyone. By experience, statutory systems are not able to guarantee these services. Private health insurance offers a wide range of options for securing lasting and solid basic coverage. It is possible to optimize and enlarge this service by providing additional features and reasonable supplements.

A survey to assess the extent of public-private mix DOTS in the management of tuberculosis in Zambia.

BACKGROUND: Involving all relevant healthcare providers in tuberculosis (TB) management through public-private mix (PPM) approaches is a vital element in the World Health Organization's (WHO) Stop TB Strategy. The control of TB in Zambia is mainly done in the public health sector, despite the high overall incidence rates. AIM: We conducted a survey to determine the extent of private-sector capacity, participation, practices and adherence to national guidelines in the control of TB. SETTING: This survey was done in the year 2012 in 157 facilities in three provinces of Zambia where approximately 85% of the country's private health facilities are found. METHODS: We used a structured questionnaire to interview the heads of private health facilities to assess the participation of the private health sector in TB diagnosis, management and prevention activities. RESULTS: Out of 157 facilities surveyed, 40.5% were from the Copperbelt, 4.4% from Central province and 55.1% from Lusaka province. Only 23.8% of the facilities were able to provide full diagnosis and management of TB patients. Although 47.4% of the facilities reported that they do notify their cases to the National TB control programme, the majority (62.7%) of these facilities did not show evidence of notifications. CONCLUSION: Our results show that the majority of the facilities that diagnose and manage TB in the private sector do not report their TB activities to the National TB Control Programme (NTP). There is a need for the NTP to improve collaboration with the private sector with respect to TB control activities and PPM for Directly Observed Treatment, Short Course (DOTS).

Public and private providers' quality of care for tuberculosis patients in Kampala, Uganda.

SETTING: The role of the private sector in tuberculosis treatment in developing countries in sub-Saharan Africa is largely unknown. In recent years, many fee-for-service clinics have opened up in Kampala, Uganda. Little is known about the tuberculosis caseload seen in private clinics or the standard of care provided to the patients. OBJECTIVE: To compare the appropriateness of tuberculosis care in private and public clinics, and the extent of the tuberculosis burden handled in the private sector. DESIGN: Cross-sectional survey in private and public clinics treating tuberculosis patients in Kampala, Uganda, during June to August 1999. MEASUREMENTS: Clinics were evaluated for appropriateness of care. This was defined as provision of proper diagnosis (sputum smear microscopy as the primary means of diagnosis), treatment (short-course chemotherapy, with or without directly observed therapy), outcome evaluation (smear microscopy at 6 or 7 months) and case notification in accordance with the Uganda National Tuberculosis and Leprosy Programme. RESULTS: A total of 114 clinics (104 private, 10 public) were surveyed. Forty-one per cent of the private clinics saw three or more new tuberculosis patients each month. None of the public or private clinics met all standards for appropriate tuberculosis care. Only 24% of all clinics adhered to WHO-recommended treatment guidelines. Public clinics, younger practitioners and practitioners with advanced degrees were most likely to provide appropriate care for tuberculosis. CONCLUSION: The private sector cares for many tuberculosis cases in Kampala; however, a new programme that offers continuing medical education is needed to improve tuberculosis care and to increase awareness of national guidelines for tuberculosis care.