It is a well-established fact that a truly innovative intervention in disease control expands the reach of public health programmes, improves patient satisfaction and health outcomes, reduces patient costs and engages all stakeholders, especially the private sector. Yet, few such innovations appear, and when they do they are often overlooked because current health programmes are either too well-established or relatively inflexible.
A case in point is a simple but transformative innovation being implemented in Mehsana, a town in Gujarat. With a part-rural and part-urban population, this town is implementing India’s first pilot for universal free tuberculosis drugs in India — an idea that could transform TB treatment and management in India. If successful, it could transform disease control altogether. TB constitutes one of the biggest health crises for India. It kills over 750 Indians every day and causes economic losses of $23.7 billion annually. Despite an extensive national programme, a large percentage of patients continue to seek care in India’s vast private sector where they believe they will get better care. Unfortunately, this is not always true. There is widespread use of inaccurate diagnostics and inappropriate treatment, pushing patients and their families into poverty and often causing drug-resistant TB, a more dangerous and harder-to-treat TB strain.
Recognising that it is unlikely to change the behaviour of private sector doctors or patients overnight, the national TB programme came up with a simple but transformational idea. It decided to provide free TB drugs to all patients in a district irrespective of whether they seek treatment in the public or the private sector.
Every time a TB case is diagnosed as set down in government guidelines, the private doctor calls the government call centre to report the case and issue a voucher for free TB drugs. Thus, the patient’s diagnosis is verified and the case notified.
The patient then goes to a designated private pharmacy where the prescription is verified to ensure treatment, and after validation the patient is given free drugs. Patients are given treatment support counselling and sent regular reminders through mobile phones to take drugs. If a patient does not pick up his or her drug refills on time, the health visitor makes a home visit.
The programme is managed by the district TB office, supported by technical partners, and has engaged a large proportion of private providers. It was executed with extensive preparatory work. All the chemists and doctors in Mehsana were mapped and engaged. Doctors were trained to help them tailor prescription practices. Uniquely, the programme offers no financial incentive to the doctor and only offers a small overheads charge to the pharmacists. In the end, the programme provides a win-win situation for all: the chemist acts as a referral point, the patient gets the right diagnosis and free drugs, and the private physician retains his or her patients.
At the heart of this innovation is the effective use of technology. A software programme was developed to link the private sector with the public health system and the call centre allowing easy reporting of cases, voucher generation and payments. The e-system ensures the chemists are paid on time for their services. It allows the patient to choose the provider, access free drugs and get adherence support conveniently.
This innovation in Mehsana can possibly transform public-private partnership and thereby the way public health programmes are run. It allows the public sector to extend core services such as testing for drug-resistant TB, household contact investigation and preventive treatment to children, helping with infection control and early diagnosis of drug-resistant TB. Its most significant impact, however, is that all TB patients in the district receive similar treatment free of cost, and are monitored, with adequate support. This has increased trust in the public system.
Over a year old, this intervention illustrates how public programmes can work with the private sector, effectively helping patients, reducing costs and improving disease-control based on the simple idea of free medicines. As its results emerge, 212 doctors and over 295 pharmacies have been engaged, benefiting hundreds of patients for now and thousands in the future.
Critics may view the programme to be technology- and resource-intensive. However, considering that India has over a “million” missing TB patients, scaling up such innovations in a phased manner seems justified and necessary.
In the end, decisions to scale up innovations must be based on not just the costs to the system but their impact on the most vulnerable. In a country like India, where a majority of the patients first seek care in the private sector, interventions such as these help in early detection and timely treatment. This programme addresses the challenges private sector patients face.
An innovation of this nature if scaled up nationally could address all these challenges.
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