A potential game-changer for the programme in India
Tuberculosis is easily one of India’s most critical public health issues, but TB prevention and control efforts face several challenges. Of these, perhaps the most significant is the effective engagement and participation of India’s vast private sector, which manages 60 per cent of all TB patients.
The private sector is highly fragmented and consists of providers of variable quality. Many TB programme managers may perceive the private sector as their main challenge and feel that engaging them would be outside the scope of their mandate. This detachment between the public and private sector is unproductive and fuels further spread of TB. Patients regularly float from one sector to the other, expending their resources and becoming more and more ill. There is also increasing evidence of a rise in the rates of drug-resistant TB — an indication that all is not well with the management of TB patients in the community.
Why does not the public programme effectively regulate or engage this sector? In many cases, managers are too preoccupied with the implementation of the DOTS programme. Other constraints to this engagement include a lack of trust on both sides, necessary skills and shortage of human resources.
Mutual distrust between public and private sectors is not new. It is fuelled by perverse market forces on the side of the private sector and antipathy on the part of the public sector. Private providers have poor compliance with the Revised National TB Control Programme’s (RNTCP) patient management strategies, with errors in diagnostics, drugs dosage and duration. Additionally, treatment adherence is a major issue — patients often stop their treatment or take medication in an irregular manner due to high costs or lack of monitoring. There is disturbing documentation on the use of inappropriate tests and prescriptions by both qualified and unqualified medical providers, leading to rising patient costs and incorrect diagnosis.
Moreover, private providers perceive TB as a clinical issue and do not always look at the community and public health perspectives of patient care, such as early diagnosis, infection control and prevention of transmission, social and psychological support and a patient-centric approach, which are necessary to achieve cure and halt transmission within the community.
India’s anti-TB programme has in the past floated public private partnership (PPP) schemes, but these have not had the necessary impact, perhaps because of insufficient benefits and incentives for the private sector.
Yet, given that the private sector treats a significant number of TB patients, its engagement is essential to achieve universal access to quality diagnosis and treatment. The sheer strength of numbers underscores the importance of an efficacious PPP model. The truth is that India’s TB burden cannot be substantially reduced unless we engage and successfully partner with the private sector.
The RNTCP is a robust public health programme, having reached over 15 million patients in the past 10 years. It has helped reduce TB prevalence and mortality, in line with the Millennium Development Goals. Similarly, there are numerous examples of clinicians in the private sector who successfully treat and cure TB patients. Yet, negative perceptions from both sides remain a major obstacle to successful partnerships.
A strategic approach to explore PPPs would include mapping the private sector in terms of core competence. Non-profit organisations such as Partnership for TB Care and Control in India (The Partnership) can provide support to State and district TB officers in the mapping exercise. Knowledge Attitude Practices (KAP) studies should explore and identify behavioural barriers within the public and private sector on PPP. The PPP strategy should include a system for accreditation of private facilities that offer the best standards of care. There will have to be stricter regulation of the sale of anti-TB drugs.
The existing PPP framework on offer from the RNTCP needs revisiting and a critical review. The concept of private providers participating through preset schemes from the RNTCP has found very few takers. There are several innovations and models of private-private and private-NGO linkages which should be fostered and scaled up. However, before a PPP model is developed, it is important to have consultations with key stakeholders including healthcare professionals, non-governmental organisations, the pharmaceutical industry for an ideal and flexible PPP system. The urgency then is for stakeholders to come together to create a strong PPP model for enhanced TB control.
Private providers should be encouraged to disseminate best practices, Standards of TB Care in India (recently brought out by the government), and encourage strict compliance with the Government of India’s ban on serology and mandatory notification of cases. The crisis of partnership in private sector engagement and monitoring of TB control can be addressed only through a participatory dialogue between private and public providers as equal and true partners. Standards of care offered to the patient should be the paramount consideration in the dialogue and the concept of “patients first” and “zero TB deaths” the common goal.
(Dr. Soumya Swaminathan is Director of the National Institute for Research in Tuberculosis, ICMR, Chennai. E-mail: firstname.lastname@example.org)