Access to quality tuberculosis (TB) treatment is increasing globally both in absolute and relative numbers. The World Health Organization (WHO) reports that 65% of the 8.7 million incident cases of TB were reported in 2010. The 2009 treatment success rate, the percentage of new, registered, smear-positive (infectious) cases that were cured or in which a full course of treatment was completed, was 86%. Despite this TB remains a significant cause of illness, resulting in 2.5 millions deaths in 2010 . TB remains a disease of the poor around the world, and the economic effects of illness can be catastrophic to low-income families [2, 3].
Part of the reason for the high rates of untreated TB in many low- and middle-income countries is that while national TB programs commonly provide effective and free diagnosis and treatment the majority of the population does not seek medical care in government facilities . The high cost of transport to government facilities and waiting times for care once there drive poorer patients to seek treatment in private settings despite higher costs of medicines and often- uncertain quality [5, 6]. Delays in treatment due to mis-diagnosis and inappropriate treatment in private settings are widespread [7–9]. Addressing the barriers faced by the poor in being treated for TB therefore requires assuring quality of care while at the same time providing accessible close-to-client care, and minimizing the direct cost of treatment.
Since 2000, WHO and the STOP TB Partnership have worked to address these issues by supporting governments in the 22 designated ‘high-burden countries’  to improve and integrate private care into national TB program strategies using a combination of methods summarized as public-private-mix-directly-observed-therapy (PPM-DOTS) [4, 10]. The efficacy of PPM-DOTS programs is measured against the four global objectives of the STOP TB Partnership: to 1/ increase TB detection rates, 2/ improve TB treatment outcomes, 3/ enhance access and equity, and 4/ to reduce financial burden upon patients.
The data for the first and second of these outcomes indicates success: PPM-DOTS programs have been effective at increasing case detection rates, and have achieved treatment completion rates that are better than non-PPM private provision, and equal or better to private DOTS initiatives in high burden countries [11, 12]. What this aggregate evidence fails to show, is whether or not the benefits of these programs are shared equitably. A recent systematic review found little evidence to indicate whether or not PPM-DOTs programs increase equity by reaching patients who were poorer, or with less access to services, than those who would receive care from traditional care sources . This study attempts to fill this gap by examining an established PPM-DOTS initiative in Myanmar to assess the extent to which it serves the poor and disadvantaged.
Myanmar is one of the poorest countries in Asia, with low overall spending on health, and an estimated TB prevalence rate (525/100,000), among the highest in the region . The government has a well-managed TB treatment program with 85% treatment success rate, however it only identifies an estimated 70% of all new cases.a Geographic access to government care limits utilization of national program centers, and there is a patient preference for private treatment, which is viewed as both more accessible, and of higher quality than government services . In response to this a number of initiatives have been created to engage private practitioners in TB identification, referral, and treatment . Among the largest is an initiative of the US-based NGO, Population Services International (PSI). PSI began working in Myanmar in 1995 and since 2003 has supported a growing number of private doctors operating branded social franchises to diagnose and treat tuberculosis .
Social franchising is a model for applying the contracting and managerial systems of commercial service franchising to social aims . Having evolved from commodity social marketing programs in Asia in the early 1990s , social franchising is now a well established method for delivering subsidized health services to large numbers of people in low- and middle-income countries around the world . While the evidence on overall effectiveness of social marketing programs remains limited , recent studies have provided indications of of improvements in access, quality, and patient and provider satisfaction using this social franchising delivery model [20–24]. A recent systematic review concluded that the evidence for impact is positive, but weak, with most studies included scoring between 2 and 4 (out of a possible 9 in a WHO-Johns Hopkins rigour scale) in terms of the strength of their study designs (Beyeler et al. unpublished).
Most social franchise programs have focused on supporting the delivery of family planning services; however there is a growing trend towards diversification . In 2007 Lonnroth et al. used archival reporting data and pre-post intervention data to demonstrated the increase in both TB diagnosis and treatments resulting from the introduction of franchised services in Yangon, and the effectiveness of the program at reaching lower income populations . That study was limited, however, by the focus on only one city, by use of a non-representative metric for socio-economic status, and by the small sample size and uncertain frame for national reporting data used.
This study uses national data on household assets and TB prevalence to determine the equity of the SQH programs. By determining national wealth estimates, and comparing both urban and rural populations to TB patients treated in SQH clinics we sought to verify the findings of Lonnroth et al., extending the equity analysis more broadly to all urban and rural areas of Myanmar, and to compare the wealth distribution of SQH-treated TB patients both to the overall population, and to the population of TB-positives across the country. Our hypotheses were that 1) TB-positive individuals would be poorer than the overall population; and 2) the SQH-treated TB patients would be poorer than the overall TB-positive population.