Collaboration or communication with private providers? Conclusions based on insufficient evidence.
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
Competing interests:
No competing interests
14 March 2006
Shifalika Goenka
Senior Research Fellow
Initiative for Cardiovascular Health Research in the Developing Countries, NDelhi-110016,
Rapid Response:
Collaboration or communication with private providers? Conclusions based on insufficient evidence.
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
Competing interests: No competing interests