Public system had weekly doses, while private practitioners opted for daily ones

The growing distrust between the public health system, which manages TB control through the Revised National Tuberculosis Control Programme (RNTCP), and the private sector physicians who are treating a significant number of TB patients outside of RNTCP, has for long been one of the crucial factors limiting the success of TB control programme.

The standard drug regimen (weekly doses) under RNTCP is in total variance with the daily drug regimen and innumerable drug combinations advised by the private practitioners, who believe in individualised treatment.

PPP models

Attempts at devising public-private partnership models (PPP), with the help of Indian Medical Association, to encourage private sector physicians and RNTCP to arrive at universal, standard TB treatments have so far met with limited success.

However, the gap may finally be bridged now that the Standards for Tuberculosis Care in India (STCI), a document drawn up by the Central TB Division in consultation with WHO and national TB institutes and brought out recently, is put into practice.

“STCI may be the way ahead for engaging private sector physicians with the RNTCP because for the first time, the government is legitimising the daily drug regimen preferred by the private sector.

STCI advises physicians to put patients under daily drug regimen, under direct observation.

Daily regimen soon

It indicates that RNTCP may also be adopting the daily regimen soon, depending on the drug logistics management,” points out R.V. Asokan, project coordinator of RNTCP for Indian Medical Association (IMA)

“This is a major step forward.

Once the drug regimen is standardised, the government can make the drugs available free of cost through private sector physicians, with adequate provisions for monitoring drug stocks,” he adds.

Guiding principle

A key guiding principle of RNTCP is the direct observation of therapy (DOT) or supervised treatment, which helps patients take drugs regularly and complete treatment.

This is necessary because the drugs are strong antibiotics with considerable side-effects, which may make the patient interrupt therapy, thus affecting cure and leading to the development of drug resistance.

DOT provider

Till now, even a local pan shop owner in the patient’s neighbourhood, who enjoys a relationship of trust with the patient, could be recognised as the DOT provider.

Now, with the help of IMA, the government is trying to promote the concept of RNTCP Public Health Institutions (PHIs), under which two private sector physicians treating TB in every TB unit (a district typically has 5 or 6 such units) would be recognised as RNTCP PHIs.

Recognition

“The recognition as an RNTCP PHI is more acceptable to the private sector physicians because it is an official extension of the national programme and is different from being a ‘DOT provider’. RNTCP will extend all services of the national TB control programme to these PHIs, so that the physician can stock drugs for individual patients and supervise treatment also,” says Dr. Asokan.

IMA has, in the past two years, trained 430 private sector physicians in the RNTCP regimen, who will be offered the PHI status.

TB was made a notifiable disease by the Centre in 2012 and a Central portal (nikshay.gov.in) was created where private sector doctors could register the TB cases which they are treating.

However, the response from private sector has been poor.

Social stigma

“Social stigma is still associated with TB and patients go to private physicians seeking confidentiality.

The physicians are reluctant to breach the patients’ trust.

These concerns are legitimate but we need the government to address these issues with the private sector so that we do not miss out on TB patients,” a senior RNTCP official said.

Social stigma was a major issue when HIV/AIDS crisis hit the nation a few years ago. Effective and continued intervention by NGOs and media had helped in reducing the stigma of HIV to a large extent, encouraging people to be open about their condition.

A similar exercise is needed in the realm of TB, so that more people come forward to be diagnosed and cured.

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