Drug-resistant TB is a challenge for resource-constrained settings where healthcare is provided by a range of healthcare providers in the public and private sectors. In countries such as Myanmar, in addition to low government funding , fragmented healthcare systems may contribute to the emergence of drug-resistance and reduce capacity to manage and diagnose drug-resistant cases [13,14,15]. To our knowledge, ours is the first study to quantitatively evaluate the health-seeking behavior of DR-TB patients in Myanmar, focusing on behavior with respect to the use of private healthcare providers.
We found that the vast majority of participants prefer to utilize the private sector and take prescribed medications from private providers when they start feeling unwell. Similar findings are reported in other Southeast and South Asian countries with dominant private sectors [16, 17]. It is important to highlight the heterogeneity of the provider landscape for allopathic health services in Myanmar and other regional countries; the private healthcare sector includes independently operating, usually unregulated GPs, pharmacies, and hospitals as well as international and local non-government organizations (NGOs) such as Population Services International (PSI). Private GPs also undertake dual practice which means that they are employed in public sector and see private patients outside of office hours as well . Thus, the diverse entities that constitute the private sector add to its complexity. In contrast to the high use of allopathic private providers, we found limited use of traditional or complementary medicine practitioners in Yangon. Finally, regardless of which provider in the private sector participants initially choose, after a diagnosis of DR-TB in the public health sector, we found that the majority switch to using the public sector and do not continue to be treated by private healthcare providers.
A highly-fragmented pathway to care with a large de-facto role for the private sector, as found in our study, can facilitate the development of DR-TB. The quality of care received at unregulated private providers is poorly studied or documented through the routine monitoring systems that are applied in the public sector. There is some evidence indicating that diagnosis and treatment in the private sector can deviate from guidelines for appropriate patient management  and that poor treatment compliance in the private sector contributes to drug-resistant TB [20,21,22]. We do not know the length of delay to diagnosis of DR-TB in Myanmar; a long delay to initiating treatment may result in spread of infection and this should be monitored among newly diagnosed DR-TB patients.
From the perspective of patient choice, use of the private or public sector is determined by both push and pull factors. Few studies in Myanmar have looked at the motivations for initially using private as opposed to public healthcare. One study found most people went to a private GP nearby since it was more convenient and was encouraged by former patients who had been cured of the disease. Long waiting times and perceived prolonged risk to exposure in the waiting rooms were also reported as deterrents to the use of the public sector .
In our study, we found that women were more likely to use private providers, consistent with other research that also found that male TB patients outnumbered females in Yangon’s public health sector . Evidence from other settings indicates that women may experience greater stigma from TB or challenges in travelling long distances to reach healthcare, and private providers may be perceived to allow greater patient privacy and be more conveniently located [24,25,26]. Further research is needed to explain other demographic differences, such as age-related disparities in seeking care from private providers.
The most likely main determinant of switching to the public sector after diagnosis with DR-TB is the high cost of future visits in the private sector, because DR-TB requires expensive medication [27, 28]. A study in Cambodia also found that patients would initially visit private healthcare providers and switch to the public sector once they knew they had TB, because they wanted to access free TB treatment which would not be available in the private sector . Proximity and access to health public facilities did not appear to be a major barrier in our study in an urban setting, with 78% of the participants able to reach NTPs within 30 min.
A major strength of this study is the collection of data via detailed, face-to-face interviews with all newly-diagnosed DR-TB participants in the studied townships, which has not previously been collected in Myanmar. However, our study is limited in that we only focus on selected townships within Yangon, and so our findings could more representative of urban settings. For example, the finding that few DR-TB patients used traditional healers may differ in rural settings. Costs of seeking care are also missing from our dataset as we did not receive ethical approval to collect this information. Likewise, our study lacks data on delays to diagnosis of DR-TB, as well as the time period between first seeking care in the private healthcare sector and shifting to the public sector. Lastly, there is considerable diversity in private sector providers that we have not investigated. Differences in quality of care, referral practices and costs may differ between registered/regulated private provider and informal or untrained providers.