Private-Sector Contribution to Tuberculosis Case Notification in Nigeria: A Systematic Review and Meta-Analysis
Abstract:
Tuberculosis (TB) remains a leading cause of infectious disease mortality worldwide, and Nigeria contributes disproportionately to the global burden. More than half of Nigerians with TB symptoms first seek care from private providers; the private sector’s contribution to national TB case notification has not been formally distilled. This review estimated the contribution following PRISMA 2020 and a registered protocol. Six databases and grey literature sources were searched from January 2000 to December 2023. Two reviewers screened records and assessed risk of bias using the Newcastle–Ottawa Scale, ROBINS-I, and JBI checklist. Proportions were pooled using the DerSimonian–Laird random-effects estimator. Heterogeneity was assessed with I², τ², and Cochran’s Q and explored through subgroup and meta-regression analyses; bias was evaluated using Egger’s test. Of 1,673 unique records screened, 28 studies met the eligibility criteria, and 18 studies (47,342 notifications) were included in the primary meta-analysis. The pooled private-sector contribution was 16.8% (95% CI 15.6–18.0; I² = 90.7%; τ² = 0.028), exceeding the WHO benchmark of 15%. Results withstood sensitivity checks. The study-level share did not change significantly over 2009–2023 (meta-regression p = 0.678). Contributions were higher in private hospitals (19.2%) and laboratories (21.0%) than in mixed portfolios (16.2%) or medicine-vendor channels (14.5%). No publication bias was detected (Egger p = 0.944). Engaged private providers account for one in six notified TB cases in Nigeria; sustaining and expanding this contribution requires an institutionalised public–private mix, predictable domestic financing, and the integration of TB notification into health insurance benefit packages.References:
[1]. World Health Organization. Global tuberculosis report
2023. Geneva: World Health Organization; 2023. p. 1-116. Available from: https://www.who.int/teams/global-tuberculosis-programme/tb-reports/global-tuberculosis-report-2023
[2].
Bagcchi S. WHO’s
Global Tuberculosis Report 2022. Lancet Microbe. 2023;4(1):e20. Available from: https://doi.org/10.1016/S2666-5247(22)00359-7
[3]. Floyd K, Glaziou P, Houben RMGJ, Sumner T, White RG,
Raviglione M. Global tuberculosis targets and milestones set for 2016-2035:
Definition and rationale. Int J Tuberc Lung Dis. 2018;22(7):723-30. Available
from: https://doi.org/10.5588/ijtld.17.0835
[4]. Adejumo OA, Daniel OJ, Adebayo BI, Adejumo EN,
Jaiyesimi EO, Akang G, et al. Tuberculosis notification in a rural local
government area of South-West Nigeria. Ann Med Health Sci Res. 2016;6(1):24-9.
Available from: https://doi.org/10.4103/2141-9248.180261
[5]. Ogbuabor DC, Onwujekwe OE. Governance of tuberculosis
control programme in Nigeria. Infect Dis Poverty. 2019;8(1):45. Available from:
https://doi.org/10.1186/s40249-019-0556-2
[6]. Obi IF, Sarki AM, Bachani AM. Driving factors for case
notification of tuberculosis in Nigeria: A systematic review. Pan Afr Med J.
2021;39:156. Available from: https://doi.org/10.11604/pamj.2021.39.156.28172
[7]. Hanson C, Osberg M, Brown J, Durham G, Chin DP.
Conducting patient-pathway analysis to inform programming of tuberculosis
services: Methods. J Infect Dis. 2017;216(Suppl 7):S679-85. Available from: https://doi.org/10.1093/infdis/jix387
[8]. Oga-Omenka C, Tseja-Akinrin A, Sen P, Mac-Seing M,
Agbaje A, Menzies D, et al. Factors influencing diagnosis and treatment
initiation for multidrug-resistant tuberculosis in six sub-Saharan African
countries: A mixed-methods systematic review. BMJ Glob Health.
2020;5(7):e002280. Available from: https://doi.org/10.1136/bmjgh-2019-002280
[9]. Sullivan BJ, Esmaili BE, Cunningham CK. Barriers to
initiating tuberculosis treatment in sub-Saharan Africa: A systematic review
focused on children and youth. Glob Health Action. 2017;10(1):1290317.
Available from: https://doi.org/10.1080/16549716.2017.1290317
[10]. World Health Organization. Public-Private Mix for TB
Prevention and Care: A Roadmap. Geneva: World Health Organization; 2018. p.
1-46. Available from: https://apps.who.int/iris/handle/10665/333885
[11]. Lei X, Liu Q, Escobar E,
Philogene J, Zhu H, Wang Y, et al. Public-private
mix for tuberculosis care and control: A systematic review. Int J Infect Dis.
2015;34:20-32. Available from: https://doi.org/10.1016/j.ijid.2015.02.015
[12]. Wells WA, Uplekar M, Pai M. Achieving systemic and
scalable private sector engagement in tuberculosis care and prevention in Asia.
PLoS Med. 2015;12(6):e1001842. Available from: https://doi.org/10.1371/journal.pmed.1001842
[13]. Gidado M, Nwokoye N, Nwadike P, Ajiboye P, Eneogu R,
Useni S, et al. Assessment of public-private mix interventions for tuberculosis
case detection in Nigeria. Public Health Action. 2021;11(2):56-62. Available
from: https://doi.org/10.5588/pha.20.0091
[14]. Adepoju VA, Adelekan A, Ogbudebe C. Effect of
community pharmacy-based tuberculosis case-finding strategy in Nigeria. Trop
Med Infect Dis. 2022;7(8):168. Available from: https://doi.org/10.3390/tropicalmed7080168
[15]. Ogbudebe CL, Adepoju V, Ekerete-Udofia C, Abu E,
Egesemba G, Chukwueme N, et al. Childhood tuberculosis in Nigeria: Disease
presentation and treatment outcomes. Health Serv Insights. 2018;11:1-7.
Available from: https://doi.org/10.1177/1178632918757490
[16]. Daniel OJ, Adejumo OA, Gidado M, Abdur-Razzaq HA,
Jaiyesimi EO. Pre-extensively drug resistant tuberculosis (Pre-XDR-TB) among
MDR-TB patients in Nigeria. Glob Adv Health Med. 2013;2(6):20-3. Available
from: https://doi.org/10.7453/gahmj.2013.054
[17]. Page MJ, McKenzie JE, Bossuyt PM, Boutron I, Hoffmann
TC, Mulrow CD, et al. The PRISMA 2020 statement: An updated guideline for
reporting systematic reviews. BMJ. 2021;372:n71. Available from: https://doi.org/10.1136/bmj.n71
[18]. Sterne JA, Hernán MA, Reeves BC, Savović J, Berkman
ND, Viswanathan M, et al. ROBINS-I: A tool for assessing risk of bias in
non-randomised studies of interventions. BMJ. 2016;355:i4919. Available from: https://doi.org/10.1136/bmj.i4919
[19]. Munn Z, Moola S, Lisy K, Riitano D, Tufanaru C.
Methodological guidance for systematic reviews of observational epidemiological
studies reporting prevalence and incidence data. Int J Evid Based Healthc.
2015;13(3):147-53. Available from: https://doi.org/10.1097/XEB.0000000000000054
[20]. DerSimonian R, Laird N. Meta-analysis in clinical
trials. Control Clin Trials. 1986;7(3):177-88. Available from: https://doi.org/10.1016/0197-2456(86)90046-2
[21]. Higgins JPT, Thompson SG, Deeks JJ, Altman DG.
Measuring inconsistency in meta-analyses. BMJ. 2003;327(7414):557-60. Available
from: https://doi.org/10.1136/bmj.327.7414.557
[22]. Egger M, Smith GD, Schneider M, Minder C. Bias in
meta-analysis detected by a simple, graphical test. BMJ. 1997;315(7109):629-34.
Available from: https://doi.org/10.1136/bmj.315.7109.629
[23]. Pai M, Behr MA, Dowdy D,
Dheda K, Divangahi M, Boehme CC, et al. Tuberculosis. Nat Rev Dis Primers.
2016;2:16076. Available from: https://doi.org/10.1038/nrdp.2016.76
[24]. Boehme CC, Nicol MP,
Nabeta P, Michael JS, Gotuzzo E, Tahirli R, et al. Feasibility, diagnostic accuracy, and effectiveness of
decentralised use of the Xpert MTB/RIF test for diagnosis of tuberculosis and
multidrug resistance. Lancet. 2011;377(9776):1495-505. Available from: https://doi.org/10.1016/S0140-6736(11)60438-8
[25]. Beyeler N, Liu J, Sieverding M. A systematic review of
the role of proprietary and patent medicine vendors in healthcare provision in
Nigeria. PLoS One. 2015;10(1):e0117165. Available from: https://doi.org/10.1371/journal.pone.0117165
[26]. Adejumo OA, Daniel OJ, Otesanya AF, Salisu-Olatunji
SO, Abdulkareem KO. Evaluation of outcomes of tuberculosis management in
private for profit and private not for profit directly observed treatment short
course facilities in Lagos State, Nigeria. Niger Med J. 2017;58(1):44-9.
Available from: https://doi.org/10.4103/0300-1652.218417
[27]. Mahendradhata Y, Lestari
T, Probandari A, Indriarini LE, Burhan E, Mustikawati D, et al. How do private general practitioners manage
tuberculosis cases? A survey in eight cities in Indonesia. BMC Res Notes.
2015;8(1):564. Available from: https://doi.org/10.1186/s13104-015-1560-7
[28]. Khan AJ, Khowaja S, Khan FS, Qazi F, Lotia I, Habib A, et al. Engaging the private sector to increase tuberculosis case detection: An impact evaluation study. Lancet Infect Dis. 2012;12(8):608-16. Available from: https://doi.org/10.1016/S1473-3099(12)70116-0
