by Luan Nguyen Quang Vo, Thuy Thi Thu Dong, Huy Ba Huynh, Binh Anh Luong, Huong Thi Lan Mo, Andrew James Codlin, Rachel Forse, Thuy Doan To Mai, Lan Phuong Nguyen, Jacob Creswell, Luong Van Dinh, Hoa Binh Nguyen, Phu Xuan Vu, Tuan Dinh Nguyen, Lan Huu Nguyen, Thi Minh Ha Dang, Son Van Luu, Nam Hoang Do, Huyen Thanh Truong, Phan Do Nguyen, Tushar Garg, Jad Shedrawy, Kristi Sidney Annerstedt, Minh Huy Pham, Jamie Tonsing, Tom Wingfield, Mohammed Ahmed Yassin, Nhung Viet Nguyen, Knut Lönnroth
Background
Treatment coverage gaps remain a major barrier to ending tuberculosis (TB). Public–private mix (PPM) entails the engagement of healthcare providers outside of national TB programs (NTP). PPM strategies are promoted to improve TB notification, particularly in high-burden settings with fragmented care systems, and intermediary agencies are recognized as effective mechanisms to operationalize PPM by bridging NTPs and out-of-network healthcare providers. However, population-level evidence is rare, as most evaluations have been limited to pilot studies, small geographic areas, or uncontrolled designs. This study documents the population-level association of a PPM intervention with TB notifications through the use of unbiased analytical methods to account for heterogeneity from the intervention’s staggered deployment and dynamic intensity.
Methods and findings
We present a non-randomized, quasi-experimental evaluation of a large-scale intermediary-facilitated PPM intervention conducted between 2020 and 2023 in 15 provinces of Viet Nam, covering 40.6 million people equivalent to 40% of the population. The intervention engaged 3,154 non-NTP providers in TB care, linking them to the NTP through systematic screening, referral, and reporting mechanisms. The model emphasized active case finding, provider incentives, patient support and integrated data systems to raise notifications as the primary outcome. We analyzed quarterly province-level TB notification data from 2016 to 2025 using a heterogeneity-robust extended two-way fixed-effects framework to estimate the average treatment effect on the treated. The analysis adjusted for province and calendar-quarter fixed effects, and for COVID-19 disruptions. Using Poisson pseudo-maximum-likelihood fixed-effects models, we estimated dose–response effects and post-intervention patterns and triangulated effects with an interrupted time-series analysis of national notifications and repeated all analyses using the intermediate outcome of PPM notifications. Lastly, we calculated marginal cost per additional notification from a funder perspective. The intervention was associated with 316.8 additional notifications per province-quarter (95% confidence interval [CI] [23.4, 610.2]; p = 0.034). Regarding dose–response effects, we observed a 1.4% increase in notifications per 100 verbal assessments per 100,000 population (incidence rate ratio [IRR]=1.00014; 95% CI [1.00002, 1.00025]; p = 0.018). National models suggested 3,206 (95% CI [1,658, 4,763]; p < 0.001) additional notifications annually with a 3.5% intensity-associated notification increase (IRR = 1.00035; 95% CI [1.00018, 1.00052]; p < 0.001). Using PPM notifications produced concordant results. The costs per additional notification were US$ 166-US$ 458. The main limitation was the non-randomized design, with high-burden provinces purposively selected as intervention areas. This was mitigated through conservative control selection and triangulation across methods.
Conclusions
This study furnishes robust, policy-relevant evidence that intermediary-facilitated PPM implemented at scale in Viet Nam was associated with significant, dose–responsive increases in PPM and TB notifications at provincial and national levels. These findings promote intermediary agency models as an effective mechanism to operationalize PPM at scale and to generate public health benefits in closing TB treatment coverage gaps. In an era of constrained global health financing, leveraging existing provider networks through intermediary-facilitated PPM offers an affordable and scalable strategy to sustain momentum towards ending TB.
Knut Lönnroth
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