Rapid Responses to:
|
|
Rapid Responses: Rapid Responses published:
-
![[Read Rapid Response]](/icons/misc/sectionDOWN.gif)
Public-private partnership for tuberculosis?
- Pierre De Paepe, Narayanan Devadasan, Werner Soors, Jean-Pierre Unger (24 February 2006)
-
Collaboration or communication with private providers? Conclusions based on insufficient evidence.
- Shifalika Goenka (14 March 2006)
-
Public-private partnerships for tuberculosis control: opportunity cost?
- Marie-Laurence Lambert, Yodi. Mahendradhata, Philippe Vinard, Marleen Boelaert, Patrick Van der Stuyft (21 March 2006)
-
Authors' Reply
- Puneet K Dewan, Knut Lonnroth, Mukund Uplekar, and Reuben Granich. (8 April 2006)
|
|
|||
|
Pierre De Paepe, Research Assistant Institute of Tropical Medicine, Department of Public Health, Antwerp, Belgium, Narayanan Devadasan, Werner Soors, Jean-Pierre Unger
Send response to journal:
|
Dewan et al.(1) recommend public-private collaboration in tuberculosis, which may be warranted in India. However, this cannot shape international TB strategy without overstretching research validity. India has a very weak public health system and patients consult private practitioners overwhelmingly. It then seems logical to aim at collaboration with these. However, - several lower-income countries have much stronger public health services ; - in Asian, Latin American and African shantytowns and rural areas, people cannot access private health care. The authors notice that in India notification rates also increased in areas where public-private mix DOTS (PPM DOTS) projects weren’t implemented. This observation considerably weakens their plea for scaling up public-private partnerships in TB as it rather indicates that good results do not imply recurring to private providers. Allegedly, analyses of two projects would “support the perception that public-private mix is cost-effective”. In fact (2), the Hyderabad project was led by a charismatic lung specialist who persuaded his private colleagues to offer services for free and in New Delhi the not-for-profit Delhi Medical Association was the partner. In both projects, the value of resources supplied to patients by the private sector at no charge was high, at US$ 30-40 per patient. Altruistic behaviour by private providers is rather atypical and it seems strange that this biased study serves to argue cost-effectiveness of PPM DOTS. The authors use this weak evidence to suggest this public-private approach for HIV-AIDS, malaria and others. However, multiplying disease specific collaborations with private providers will be expensive. Why not strengthen health services and integrate disease control programmes into daily curative activities (3), as recommended by WHO (4)? It has been mathematically demonstrated that increasing utilization rates of public health services has the largest effect on malaria cure rates(5). These results can easily be reproduced for TB. Reference List (1) Dewan PK, Lal SS, Lonnroth K, Wares F, Uplekar M, Sahu S et al. Improving tuberculosis control through public-private collaboration in India: literature review. Br Med J 2006; doi:10.1136/bmj.38738.473252.7c published 16 Feb 2006. (2) WHO. Cost and cost-effectiveness of public-private mix DOTS: evidence from two pilot projects in India. Dots Expansion Working Group, editor. WHO/HTM/TB/2004.337, 1-53. 2006. Geneva, Switzerland. Stop TB Partnership. (3) Buvé A, Kalibala S, McIntyre J. Stronger health systems for more effective HIV/AIDS prevention and care. Int J Health Plann Manage 2003; 18:S41-S51. (4) Jong-wook L. Global health improvement and WHO: shaping the future. Lancet 2003; 362(9401):2083-2088. (5) Unger JP, D'Alessandro C, De Paepe P, Green A. Can malaria be controlled where basic health services are not used? [In Press]. Trop Med Int Health 2006. Competing interests: None declared |
|||
|
|
|||
|
Shifalika Goenka, Senior Research Fellow Initiative for Cardiovascular Health Research in the Developing Countries, NDelhi-110016,
Send response to journal:
|
In India, we have poor case notification of tuberculosis and other common diseases. The reason being that 79-85% of the population access private providers.(1;2;2;3) These cases never get reported. The poor and the disadvantaged sections are more susceptible to tuberculosis(4;5) and are more likely to go to private providers. The reasons why people access private doctors and not public health clinics are deep, varied and multiple. The estimated prevalence of smear positive tuberculosis is 333/100, 000 population (age group >= 15 years). The corresponding figure for smear negative but culture positive cases is 332/100, 000 population. In addition to this, the prevalence of sputum negative, X-Ray positive patients is estimated to be 2360/100, 000 population.(6) In clinical practice in India, physicians know that only a minority of cases are smear positive. Nevertheless they all require treatment. Given the burden of smear negative tuberculosis cases, I was wondering why, only data on smear positive cases is presented. It has been documented that smear positive target driven programs tend to systematically exclude the marginalized tuberculosis patients during enrolment itself.(7) In my intensive two year ethnographic experience with private practitioners in Delhi, I learnt that there was no communication between private and government doctors; I learnt that there were very poor patients who just could not afford to buy their daily medications. Doctors, in such cases, were desperately looking for a place, convenient for the patients, where they could go and would be provided free credible medication (drugs), and diagnosis (as against being told that medicines are out of stock come after a week etc ). Tuberculosis treatment is expensive for the poor patient. At any point in time the successful practitioners would have anywhere between 15-50 patients coming to them for tuberculosis. Many were dispensing practices and patients came everyday to buy their medicines from the doctor. A mere availability, or expansion, or increase in outreach of the public health system in providing tuberculosis treatment is bound to increase case notification over time. In a background where there is no communication between private doctors and government doctors, mere communication about such a service would help. (if the patient found the health-care friendly then more patients would move from private providers, through word of mouth) From the articles used in the review it is difficult to find out, or tease out, whether it was ‘collaboration’ or mere ‘communication’ or awareness of mere credible presence ‘or simply greater outreach or expansion as mentioned in the review. The DOTS administration (table1) reported has been done by RNTCP, DMA, NGOs or corporate providers only. Also, there is no comparison between others tuberculosis centers without “private collaborations” to credibly conclude that there was improvement with “private collaboration”. Another point of view is that since patients first go to private providers, most patients in the DOTS enrolment would be defacto from private providers. A review article requires a basic amount of data to be reviewed. Private sector consists largely of sole practitioners or small nursing homes having 1-20 beds, serving the urban and semi-urban clientele and focused on curative care.(8) Majority of the examples used in the review cannot be called private setups and many are organizations where service and philanthropy is done many through private donations, charitable trusts or government funding. Corporate houses which employ large numbers of unskilled labour (tea, beedis. mining, sugar mills), typically in rural, semi-urban settings would welcome any government help to treat their tuberculosis patients - it would decrease the costs of their health-care bills (if corporates are providing health care), and help in a healthier workforce (even if the corporate is not providing health-care). In addition, beedi workers because of greater exposure to tobacco would be more susceptible to pulmonary tuberculosis(9) and consequently the prevalence of tuberculosis would be much higher in these settings. A mere expansion to such areas would increase case notification. Kerala, in India, is a unique state, socio-economically advanced with 100% literary levels, and is different from any other state in India. Data from this state cannot be extrapolated or generalized to the rest of the country or to any other state in the country. Lastly but importantly, public private collaborations is the new fashionable buzzword in all meetings here these days where at least one lecture or session is dedicated to it. It however rarely has representation of the common private provider. Every one seems to be pushing this agenda but it is somewhere dangerously translating into a poor resolve and insufficient action to strengthen the public health services in India. Sadly, such articles tend to further endorse and advocate it. Reference List (1) A Vision for India's Health System.Chapter 5- Functioning of the Private Sector Market. World Bank. Report available at www.worldbank.org/sar. Accessed on 16th November 2004; 2004. (2) Misra R, Chatterjee R, Rao S. Changing the Health System: Current Issues, Future Directions. Commission on Macroeconomics and Health. Indian Council of Research on International Economic Relations. New Delhi; 2002. (3) Duggal R. The Private Health Sector in India. Nature, Trends and a Critique. From the Detail Report of "The Independent Commission on Health in India". New Delhi: Mukhopadhyay A; 2000. (4) Shiva M. Malaria and tuberculosis: our concerns. Health Millions 1997 Mar;23(2):2-3. (5) Bhagyalaxmi A, Kadri AM, Lala MK, Jivarajani P, Patel T, Patel M. Prevalence of tuberculosis infection among children in slums of Ahmedabad. Indian Pediatr 2003 Mar;40(3):239-43. (6) Dua A, and others. Burden of Tuberculosis in India for the Year 2000. National Commision on Macroeconomics and Health, MInistry of Health and Family Welfare, Government of India; 2005 Sep 9. (7) Singh V, Jaiswal A, Porter JD, Ogden JA, Sarin R, Sharma PP, et al. TB control, poverty, and vulnerability in Delhi, India. Trop Med Int Health 2002 Aug;7(8):693-700. (8) Rao S, Nundy M, Dua A. Delivery of Health Services in the Private Sector. National Commision on Macroeconomics and Health, Ministry of Health and Family Welfare, Govt of India; 2005 Aug 8. (9) Reddy K, Gupta P. Smoking and Pulmonary Tuberculosis. Ministry of Health and Family Welfare, Govt of India and Centers fro Disease Control and Prevention, USA, WHO; 2004 Nov 24. Competing interests: None declared |
|||
|
|
|||
|
Marie-Laurence Lambert, Public health expert B-1040 Brussels, Yodi. Mahendradhata, Philippe Vinard, Marleen Boelaert, Patrick Van der Stuyft
Send response to journal:
|
Sir, While recognizing the impressive progress achieved in tuberculosis (TB) control in India over the last years, we feel that the conclusions of the article by Dewan & al(1) have overlooked some important points as regards the potential hold by public-private partnerships (PPP). The data presented do not permit to appraise the efficiency of, in particular, collaborations with private practitionners (PPs). Indeed each individual PP is likely to see few patients. Data on time frame and number of PPs involved are presented only for 2 out of 6 such projects discussed in the article. In Mumbai, 1018 PPs evaluated over 18 months detected 910 new patients, that is 0.60 new patient per PP per year (0.69 patients/PP/year in the much smaller Thane Municipal project). In Mumbai, a ‘one-to-one’ approach - involving individual visits to each PP - is now used. This is resource-intensive and raises questions on cost and cost-effectiveness of this strategy. One of us (PV) visited Mumbai recently. He observed discrepancies between official data on coverage of public health services, and the field reality. For instance, large illegal shanty settlements known as ‘dark areas’, not ‘officially’ existing, are not eligible for public health services, and the overall number of facilities available for TB diagnosis and treatment in Mumbai is far below the targets of one laboratory per 100.000, and one treatment centre per 20.000 population. Access to treatment is particularly problematic. The Mumbay District Tuberculosis Control Society reports that out of 3065 patients diagnosed with smear- positive tuberculosis during the 4th quarter 2004, only 57% were registered for treatment (unpublished report). Some research in India has documented similar problems, such as inadequate public health infrastructure in Mumbai(3) or difficult access to TB treatment in Delhi(4). Our personal experience in Indonesia (YM) suggests that the contribution of PPP to TB case detection is most significant in regions where the TB programme is weak, and much less where the TB programme is strong; the sustainability of resource-intensive, externally funded PPP is also questionable. In such contexts, National TB Control Programmes cannot ignore the opportunity cost of involving private practitionners in tuberculosis control. Dewan & al(1) further quote the recent economic analysis of PPP in India by WHO to support ‘the perception that PPP are cost- effective’(4). But, by their own admission, the authors of the economic study did not compare the cost-effectiveness of investment in PPP with the cost-effectiveness of similar investments in the public sector. PPP have potentially very important implications for tuberculosis control, and for people such as the inhabitants of Mumbai’s shanty settlements. Advocacy for it need to be supported by appropriate research that critically analyses not only their strengths, as in this article, but also their limitations, and costs. (1) Dewan PK, Lal SS, Lonnroth K, Wares F, Uplekar M, Sahu S, Granich R, Chauhan LS. Improving tuberculosis control through public-private collaboration in India: literature review. BMJ. 2006 Mar 11;332(7541):574-8. (2) Rangan S, Ambe G, Borremans N, Zallocco D, Porter J. The Mumbai experience in building field level partnerships for DOTS implementation. (3) Singh V, Jaiswal A, Porter JD, Ogden JA, Sarin R, Sharma PP, Arora VK, Jain RC. TB control, poverty, and vulnerability in Delhi, India. Trop Med Int Health. 2002 Aug;7(8):693-700. (4) WHO. Cost and cost-effectiveness of Public-Private Mix DOTS: Evidence from two pilot projects in India. Geneva:WHO/HTM/TB/2004.337, 2004. Competing interests: None declared |
|||
|
|
|||
|
Puneet K Dewan, Medical Officer Centers for Disease Control and Prevention, Atlanta GA 30333, USA, Knut Lonnroth, Mukund Uplekar, and Reuben Granich.
Send response to journal:
|
Dear Editors, We agree with the respondents on the critical importance of strengthening public health services. The public sector is and will remain responsible for most health care delivery to poor patients. However, a private health care sector exists nearly everywhere, in rural and urban areas alike. Growing evidence suggests that even the poorest in Africa and Asia often access health services from the private sector, through small private clinics, workplace health services, non-governmental organizations, or providers of alternative traditional systems of medicine.(1-5) Public-private collaboration is about recognizing that reality, improving quality of care among providers who already diagnose and treat patients, and reducing costs to patients in need. Such collaborations are complimentary to public sector services, and should not be seen as a threat but rather as an opportunity to improve the health of patients wherever they choose to seek care. As we have noted, in the projects we reviewed effective collaboration required a strong public sector for advocacy, training, and supervision of private sector activities.(6) Different degrees of collaboration may be appropriate in different settings. Collaboration is of course a two-way street. Any provider diagnosing or treating tuberculosis patients should strive to provide care in accordance with international standards.(7, 8) National tuberculosis programmes can help providers adhere to standards and meet their public health responsibilities. Introducing or scaling up the public private mix approach in DOTS is an integral component of the new Stop TB Strategy and the Global Plan to Stop TB.(9) Although we focused on public private collaborations in India, these findings may be relevant in many settings. The evidence on cost- effectiveness is limited but growing; additional evaluations from Myanmar, Philippines, Kenya, Bangalore (India), and other settings are expected. These may help determine if this promising approach will indeed have the intended impact of improved health and reduced costs to patients. References 1. Makinen M, Waters H, Rauch M, Almagambetova N, Bitran R, Gilson L, et al. Inequalities in health care use and expenditures: empirical data from eight developing countries and countries in transition. Bull World Health Organ. 2000;78(1):55-65. 2. Hanson K, Berman P. Private health care provision in developing countries: a preliminary analysis of levels and composition. Health Policy Plan. 1998 Sep;13(3):195-211. 3. Mills A, Brugha R, Hanson K, McPake B. What can be done about the private health sector in low-income countries? Bull World Health Organ. 2002;80(4):325-30. 4. Marek T, O'Farrel C, Yamamoto C, Zable I. Trends and opportunities in public-private partnerships to improve health service delivery in Africa. Washington D.C.: World Bank; 2005. 5. Palmer N, Mills A, Wadee H, Gilson L, Schneider H. A new face for private providers in developing countries: what implications for public health? Bull World Health Organ. 2003;81(4):292-7. 6. Dewan PK, Lal SS, Lonnroth K, Wares F, Uplekar M, Sahu S, et al. Improving tuberculosis control through public-private collaboration in India: literature review. Bmj. 2006 Mar 11;332(7541):574-8. 7. Tuberculosis Coalition for Technical Assistance. International Standards for Tuberculosis Care (ISTC). The Hague: Tuberculosis Coalition for Technical Assistance; 2006. 8. World Care Council. The Patients' Charter for Tuberculosis Care: Patients' Rights and Responsibilities: World Care Council; 2006. 9. The Global Plan to Stop TB, 2006-2015: The Stop TB Partnership; 2006. Competing interests: None declared |
|||