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Over the past decade, there has been a rapid increase in the number of initiatives involving "for-profit" private health care providers in national tuberculosis (TB) control efforts. We reviewed 15 such initiatives with respect to contractual arrangements, quality of care and success achieved in TB control. In seven initiatives, the National TB Programme (NTP) interacted directly with for-profit providers; while in the remaining eight, the NTP collaborated with for-profit providers through intermediary hot-for-profit nongovernmental organizations. All but one of the initiatives used relational "drugs-for-performance contracts" to engage for-profit providers, i.e. drugs were provided free of charge by the NTP emphasizing that providers dispense them free of charge to patients and follow national guidelines for diagnosis and treatment. We found that 90% (range 61-96%) of new smear-positive pulmonary TB cases were successfully treated across all initiatives and TB case detection rates increased between 10% and 36%. We conclude that for-profit providers can be effectively involved in TB control through informal, but well defined drugs-for- performance contracts. The contracting party should be able to reach a common understanding concerning goals and role division with for-profit providers and monitor them for content and quality. Relational drugs-for-performance contracts minimize the need for handling the legal and financial aspects of classical contracting. We opine that further analysis is required to assess if such "soft" contracts are sufficient to scale up private for-profit provider involvement in TB control and other priority health interventions. Engagement productif des prestateurs prives dans la lutte antituberculeuse : des benefices bien reels sans contrat Ieonin Au cours de la derniere decennie, on a observe une rapide augmentation du nombre d&apos;initiatives impliquant des prestateurs de soins de sante prives (<>) dans les efforts de lutte contre la tuberculose. Nous avons analyse 15 de ces initiatives sous l&apos;angle des dispositions contractuelles, de la qualite des soins et des succes obtenus dans la lutte antituberculeuse. Dans le cas de 7 d&apos;entre elles, le programme national de lutte contre la tuberculose (PNT) traitait directement avec des prestateurs exercant une activite lucrative, tandis que dans le cadre des 8 autres, le PNT collaborait avec des prestateurs a but lucratif, par l&apos;intermediaire d&apos;organisations non gouvernementales a but non lucratif. Toutes ces initiatives sauf une faisaient appel aux prestateurs a but lucratif en passant avec eux des contrats relationnels << Medicaments contre prestations >>, c&apos;est-a-dire que les medicaments leur etaient fournis gratuitement par le PNT a la condition explicite qu&apos;ils les distribuent gratuitement aux patients et qu&apos;ils respectent les directives nationales en matiere de diagnostic et de traitement. Nous avons constate que, pour l&apos;ensemble des initiatives, 90% (plage de variation : 61 - 96 %) des nouveaux cas de tuberculose pulmonaire a frottis positif avaient ete traites avec succes et que le taux de detection de la tuberculose aurait augmente de 10 a 36 %. Nous avons conclu que les prestateurs a but lucratif pouvaient participer efficacement a la lutte antituberculeuse par l&apos;intermediaire de contrats informels, mais bien definis sous l&apos;angle de la condition : medicaments contre prestations. La partie contractante doit etre en mesure de parvenir a un accord concernant les buts et la repartition des roles avec les prestateurs a but lucratif et de surveiller le contenu et la qualite de leurs prestations. Les contrats relationnels de type Medicaments contre prestations n&apos;exigent qu&apos;une prise en compte minimale des aspects juridiques et financiers couverts par les contrats classiques. Nous sommes d&apos;avis qu&apos;une analyse plus poussee s&apos;impose pour evaluer si ces contrats <> suffisent pour elargir la participation des prestateurs prives a but lucratif a la lutte antituberculeuse et a Ventajas de los contratos relacionales: contratacion productiva de proveedores privados en la lucha contra la tuberculosis En el ultimo decenio han proliferado rapidamente las iniciativas que recurren a proveedores de atencion sanitaria privados con animo de lucro en las actividades nacionales de lucha contra la tuberculosis. Examinamos los acuerdos contractuales, la calidad de la asistencia prestada y los resultados obtenidos en la lucha contra dicha enfermedad en 15 iniciativas de ese tipo. En siete de ellas, el Programa Nacional contra la Tuberculosis trabajaba directamente con proveedores con animo de lucro, y en las ocho restantes colaboraba con proveedores con animo de lucro a traves de organizaciones no gubernamentales no lucrativas. Exceptuando un caso, en todas las iniciativas se recurrio a <> para hacer participar a los proveedores con animo de lucro, esto es, el Programa les proporcionaba los medicamentos de forma gratuita, pero insistiendo en que se dispensaran tambien gratuitamente a los pacientes y con arreglo a las directrices nacionales en materia de diagnostico y tratamiento. Observamos que en todas las iniciativas el 90% (intervalo: 61%-96%) de los nuevos casos baciliferos de tuberculosis pulmonar habian sido tratados satisfactoriamente, y que las tasas de deteccion de casos aumentaron entre el 10% y el 36%. Nuestra conclusion es que los proveedores con animo de lucro pueden participar de forma eficaz en la lucha antituberculosa mediante contratos informales, pero bien definidos, de medicamentos por prestaciones. La parte contratante debe poder llegar a un consenso sobre los objetivos y el reparto de las funciones con esos proveedores, y vigilar el contenido y la calidad de sus servicios. Los contratos de medicamentos por prestaciones reducen al minimo la necesidad de ocuparse de los aspectos juridicos y financieros de los contratos ordinarios. Consideramos que es conveniente realizar un analisis en mayor profundidad para determinar si esos contratos simplificados bastan para extender masivamente la participacion de los proveedores privados con animo de lucro en la lucha contra la tuberculosis y en otras intervenciones de salud prioritarias. [TEXT NOT REPRODUCIBLE IN ASCII.], Introduction Private health care providers play a prominent role in delivering curative services in the majority of low-income countries. (l-5) They are often the first point of contact for a [...]

Abstract Background Human resources (HR) constraints have been reported as one of the main barriers to achieving the 2005 global tuberculosis (TB) control targets in 18 of the 22 TB high-burden countries (HBCs); consequently we try to assess the current HR available for TB control in HBCs. Methods A standard questionnaire designed to collect information on staff numbers, skills, training activities and current staff shortages at different health service levels was sent to national TB control programme managers in all HBCs. Results Nineteen HBCs (86%) replied, and 17 (77%) followed the questionnaire format to provide data. Complete information on staff numbers at all service levels was available from nine countries and data on skill levels and training were complete in six countries. Data showed considerable variations in staff numbers, proportions of trained staff, length of courses and quality of training activities. Eleven HBCs had developed training materials, many used implementation guidelines for training and only three used participatory educational methods. Two countries reported shortages of staff at district health facility level, whereas 14 reported shortages at central level. There was no apparent association between reported staff numbers (and skills) and the country's TB burden or current case detection rates (CDR). Conclusion There were few readily available data on HR for TB control in HBCs, particularly in the larger ones. The great variations in staff numbers and the poor association between information on workforce, proportion of trained staff, and length and quality of courses suggested a lack of valid information and/or poor data reliability. There is urgent need to support HBCs to develop a comprehensive HR strategy involving short-term and long-term HR development plans and strengthening their HR planning and management capabilities.

We welcome the commentary "Addressing Smoking Cessation in Tuberculosis Control" responding to the Bulletin theme issue on tuberculosis (May 2007), and thank the authors for raising this important issue. If [...]

Tuberculosis (TB) is one of the major causes of illness and death in many countries and a significant public health problem worldwide. Its importance as a barrier to socioeconomic development [...]

Tuberculosis (TB) has been a major killer disease for several thousand years. Despite intensive efforts to combat the disease over the past twenty years, TB remains one of the leading [...]