# Barriers and facilitators of implementing public–private mix approaches for active tuberculosis case finding and health insurance access in at-risk populations in Ghana: a qualitative study

## TL;DR

This study explores what helps or hinders a public-private mix approach to find more tuberculosis cases and improve health insurance access in Ghana.

## Contribution

The study identifies specific facilitators and barriers to implementing a PPM model for TB case finding and insurance access in at-risk populations.

## Key findings

- Strong collaboration and adaptable screening helped implement the PPM model effectively.
- NHIS reimbursement delays and poor communication limited the model's sustainability.
- Community engagement and routine TB screening integration improved program uptake.

## Abstract

In Ghana, although free tuberculosis (TB) services are provided at public facilities, the TB case detection rate is still lower than anticipated. To enhance TB case detection, private community healthcare providers and the National Health Insurance Scheme (NHIS) have been involved using a Public-Private Mix (PPM) model, which includes active case finding (ACF) and access to insurance. This study examines the facilitators and barriers to implementing a PPM model that aims to expand ACF and provide health insurance to newly diagnosed TB patients among at-risk populations in two Ghanaian cities.

This was an exploratory qualitative study based on 54 TB patient exit interviews, key informant interviews from seven sub-metro TB coordinators and 44 facility-level TB coordinators, and six focus group discussions were held, comprising four with health workers (n = 53) and two with volunteers (n = 18). We conducted a thematic content analysis and, based on the key themes identified, we applied the Consolidated Framework for Implementation Research (CFIR) to structure the themes across five domains.

Implementation of the PPM model was facilitated by strong stakeholder collaboration, adaptable screening procedures, adequate diagnostic resources, and effective supervision. However, delays in NHIS reimbursements, limited registration logistics, weak intersectoral communication, and high staff turnover constrained implementation. While community engagement and the integration of TB screening into routine care enhanced uptake, persistent financial and operational barriers limited the program's sustainability.

The PPM model increased TB case detection and expanded insurance coverage but was limited by structural inefficiencies, especially within NHIS operations. Future efforts should address systemic misalignments, support healthcare workers, and improve NHIS-private provider collaboration. Recognizing facilitators and barriers can help policymakers, TB program managers, NHIS officials, and partners plan more effective PPM models to boost active case finding in Ghana and similar settings.