Improving tuberculosis control through public-private collaboration in India: literature review
BMJ 2006; 332 doi: https://doi.org/10.1136/bmj.38738.473252.7C (Published 09 March 2006) Cite this as: BMJ 2006;332:574
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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
Competing interests: No competing interests
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
Competing interests: No competing interests
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
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
Competing interests: No competing interests
Re: Improving tuberculosis control through public-private collaboration in India: literature review
Elderly patients diagnosed with pulmonary tuberculosis have been given the run around for registrations and other formalities if they wish to get free treatment.
If any person reports TB through a helpline number, there should be the provision of one person to visit the house, authenticate, register and provide ATT, then only RNTCP can become successful; otherwise, there is no use making websites, registries, when the patient is not getting care - everything else is secondary and useless.
One solution is to use the Health Account Scheme [1] to bridge this gap in service delivery. Otherwise the Revised National tuberculosis control program, no matter how good it looks on paper and on the website, remains a flop at ground level. The said target of TB free India can be completed within the allocated budget and logistics in RNTCP - but currently it is not efficiently deployed and not user-friendly as it still requires patients to visit the centers very frequently and waste a long time on processing there.
Ref.
Neeta Kumar, Neeru Gupta et al. Digital Diary Tool Under Health Account Assessment For Community Participation And Action: An Implementation Experience From Rural, Urban And Tribal Field Sites In India. International Journal of Health Systems and Implementation Research-2018; 2(2): 4-17.
Competing interests: No competing interests