The National Tuberculosis Control Programme in South India

Assessment of public private mix in the Revised National Tuberculosis Control Programme in a south Indian district

 

In India, Tuberculosis (TB) remains a major global health problem, accounting for 26 per cent of all TB cases worldwide (Global Tuberculosis Report 2013). The revised national TB control programme (RNTCP) was launched in India in 1997 based on the World Health Organization advised directly observed treatment (DOT) strategy, by incorporating several strategies. One of such strategies was, Public Private Mix (PPM) with an objective to engage all private sector providers (PSPs) in RNTCP to provide universal access to TB care.

There is a large body of evidence to demonstrate that PSPs are the first choice for seeking TB care in India (^{23,24,25,26,27,} Uplekar M, Pathania V, Raviglione M. Private practitioners and public health: weak links in tuberculosis control. The Lancet 2001; 358: 912–916). TB is often inaccurately diagnosed and ineffectively treated in the private sector leading to poor treatment outcomes and acquired drug resistance.^{12,13,14,15,16,17,18,19,20}. Recognising the critical need to engage PSPs in the RNTCP, the Government of India (GoI) rolled out PPM schemes in 2001-20012 to collaborate with PSPs, to ensure early detection of TB and provide standardised treatment to TB patients. Currently there are ten PPM schemes, principally based on results based financing (Box 1). Each scheme has specific objectives that the partnership is expected to fulfill by signing a Memorandum of Understanding with the district TB officer (DTO).

There are numerous studies and evaluations of PPM initiatives in India showing positive impact on case detection, treatment success rates and demonstrating feasibility and cost-effectiveness of PPM strategy, but confining to one particular setting/context. There are very few documented studies on the contribution of PPM to case finding in India and there are none on the contribution of private practitioners (PPs) to RNTCP under programmatic settings. It is against this background that we conducted this study to assess the participation of PPs in RNTCP through PPM schemes and to document their contribution to TB case finding in a district from South India. We focused on for-profit, formally trained PPs working in clinics, nursing homes and hospitals.

Materials and methods:

Setting: This study was carried out in Karnataka, South India (total population 2,716,997). Like anywhere else in India, health care is provided free of cost in public sector health facilities. There is a dominant private health sector, with wide array of healthcare providers ranging from unqualified practitioners to highly trained specialists. Tumkur district is divided into seven Tuberculosis Units (TUs), each catering to a population of 500,000 and responsible for the programme implementation. Under each unit, there are Designated Microscopy Centers (DMCs), each catering to a population of 100,000 and performing AFB sputum microscopy (n= 28 in the district). The number of DOT centers in the district is 2402. Patients can either directly access these centers or can be referred by any PSP. Laboratory technicians at DMCs are expected to record the details of the referring PP or health facility in the laboratory register for each presumptive TB case examined there.

Definitions

PPs were defined as ‘formal’ if they were formally trained either in allopathic medicine or in the Indian system of medicine, AYUSH (Ayurveda, Yoga and Naturopathy, Unani, Sidda and Homeopathy).

Specialists were defined as PPs who have an advanced training and we categorized them into (i) ‘relevant’: who potentially see TB patients in their routine practice such as, chest physicians, general physicians (specialists in general medicine), surgeons, pediatricians, gynecologists and (ii) ‘non- relevant’: who rarely see TB patients in their routine practice such as ENT surgeons, ophthalmologists, dermatologists, radiologists, anesthetists, etc.

Data collection

We assessed PP’s participation for the year 2011. We collected data retrospectively from RNTCP’s routine reports and registers from August to October 2012.

To document the total number of PPs involved in PPM schemes, information was retrieved from the District TB Center (DTC) and verified at the state TB office located in Bangalore.

To assess the total number of PPs referring presumptive TB cases to RNTCP for sputum examination and ascertain the volume of referrals by them, data was collected from laboratory registers from all the 28 DMCs present in the district. Individual names of referring PPs and number of referrals, were extracted systematically and entered in the data base. We cross-verified the data with routine quarterly reports and records generated at DTC.

During our data collection we observed that only few DMCs had good documentation of PP’s referrals. Hence, for the next step and the final analysis we selected 5 DMCs with reliable documentation (Sira town, Koratagere town, Kunigal town, SVIRHC DMC of Pavagada town and the District TB Centre DMC of Tumkur city).

Due to the absence of a registry of PPs in the study area, we conducted mapping of PPs using 5 sources: Indian Medical Association, Karnataka Private Medical Establishment Act, DTC, private nursing homes association, medical college and onsite verification. To ascertain the characteristics of PP, whether formal or informal (no training whatsoever), for profit or not-for-profit, the type of medicine practiced (AYUSH or allopathy) and the type of health facility (clinic, nursing home or hospital), we visited PP’s health facilities and documented the relevant details.

Data was analyzed using Excel.

Ethics

The collected data was secondary from routine RNTCP registers and reports. Hence it did not pose any ethical concerns.

Results:

• None of the PPs in the district had formally signed-up/taken up any existing PPM scheme during the year 2011. PPs referred presumptive TB cases to RNTCP on an ad hoc basis, without any formal communication with the programme.
• We identified a total of 424 formal PPs practicing in the study area (365 allopaths and 59 AYUSH).
• Of the 424 PPs, 95 (22%) had made at least one referral during the year (table 1). Among 279 specialists, 57 (20%) had made at least one referral, 41(48%) among 94 allopathic general practitioners (GPs) and 6 (10%) among the AYUSH.
• There was total 675 presumptive TB case referrals by all PPs. 316 cases were referred by GPs, 344 by specialists and 15 by AYUSH providers. For the referring PPs, the median number of referrals per PP was 2 with an inter quartile range from 1-7. No major variation was observed in the referral pattern between specialists and GPs (table 2)
• Among total 4446 presumptive TB cases examined at DMCs, PPs contributed to 15% of all the presumptive TB cases examined at DMCs (table 3)., 157(23%) of the presumptive TB cases referred by PPs were smear positive. PPs contributed to 23% of the detected sputum smear positive TB cases. Wide variation was observed across different DMCs.

Table 1 : Total number and proportion of PPs referring presumptive TB cases to RNTCP in Tumkur district, 2011

Table 2 : Volume of referrals per PP in Tumkur district, 2011

Table 3: Number of presumptive TB cases examined and number found smear positive in Tumkur district, 2011

Discussion:

Poor involvement of PPs:

Our study demonstrates the complete absence of formal engagement of PPs with RNTCP, twelve years after launching PPM schemes. However, 22% of PPs in the study area had made at least one referral during the study period, contributing to 23% of detected sputum positive cases in the district. This goes to say that the engagement exists between the RNTCP and PPs, but is mainly informal(similar to a study by Lönnroth etal (Soft Contracts with Private Practitioners to Improve Tuberculosis Outcomes; Lönnroth, Uplekar, and Blanc (2006). Among allopaths, almost half of GPs had made at least one referral during the study period, but among relevant specialists it was only 27%. Positivity rate of 23% among the presumptive TB cases referred by PPs is much higher than normally expected value of 10%, suggest that PPs do make selective referrals to RNTCP instead of referring all chest symptomatics in their routine practice. PPs should be encouraged for correct selection of presumptive TB cases to be referred.

Mapping:

Due to the absence of PP’s registry in the study area, we used various data sources to map PPs in the study area, which was time consuming and resource intensive. Good situational analysis of private sector landscape to assess their competencies, qualification and strengths, is a prerequisite for effective and involvement of PPs who could potentially collaborate with RNTCP. It is imperative that TB programme does a periodic private sector mapping in the region depending upon the tasks expected by the RNTCP of the PPs ( For example Lonnroth K and Uplekar M (unpublished) have listed several possible tools). In India health sector is pluralistic. A clear guidelines should be developed by GoI, guiding the programme managers to carry out the mapping of PSPs in the area will prove useful (Lonnroth K, Uplekar M. Practical tools for involving private health care providers in TB control. Stop TB. Geneva: World Health Organization, Geneva. Document in preparation)

Reporting: There are number of evaluations of various PPM initiatives showing positive impact on case detection and treatment success Rates. However, routine monitoring of PPM to RNTCP is yet to be introduced. RNTCP boasts of having robust reporting mechanism. But, the data generated either of case detection or treatment outcomes is only about those patients notified by public sector health facilities and does not include contributions made from PSPs (measuring PPM contribution to TB care and Global TB report 2012). Though there has been many efforts by GoI to engage with PPs, there is little or no efforts in strengthening the PPM reporting system. India introduced PPM recording and reporting system in 14 cities where PPM was scaled up and intensified. However, the system was judged to be too cumbersome for regular and countrywide reporting ( measuring PPM contribution to TB care). PPM data generated currently in the programme are not disaggregated according to type of PP. These aggregated numbers are not useful to the programme mangers either for planning or making any decisions in PPM area. There are several recording and reporting tools developed by WHO and other organisations, to advice countries on effective data collection, management and how to monitor PPM activities (measuring PPM contribution to TB care ( in publication folder). RNTCP may consider developing simple tools for routine PPM data collection and reporting (Development of evaluatory and monitoring mechanisms for ongoing PPP projects) (Major Barriers to Public-Private Collaboration(WHO/ & CDS/TB/2001.285., 2001). The monitoring and supervision mechanism within medical colleges to oversee the implementation of RNTP could serve as a positive model for designing a system for PPM monitoring and evaluation.

PPM schemes: Though many PPs are referring substantial number of TB suspects there is no formal financial payments made to them, as there is no provision for incentivising them for referrals in the existing PPM schemes. Our study shows that none of the PPs have signed an MoU with NTP to get involved with NTP through any available PPM schemes. The partnership between NTP and PPs is restricted to informal TB suspects referrals only. Annual report of RNTCP, 2013 reports that XXX PPs are collaborating under various PPM schemes. But, in reality they comprise only a miniscule part of the large private sector in the country. This issue needs further evaluation as to why PPs prefer informal agreements to collaborate with NTP (Lönnroth, Uplekar, & Blanc, 2006). It is also important to explore further as to what approaches or strategies would work for building long term sustainable collaboration with PPs. (WHO/ & CDS/TB/2001.285., 2001)

Conclusion: Studies shows that nothing has changed in last two decades in the poor TB management practices by PPs (Udwadia, Pinto, & Uplekar, 2010) and engagement of PSPS to generate referrals to RNTCP for diagnosis and/or treatment, has had limited success.(Sachdeva, Kumar, Dewan, Kumar, & Satyanarayana, 2012). Our study re emphasises the poor engagement of PPs in TB care and call for immediate actions to revitalise the PPM activities. The vision of the GoI is for a ‘TB free India’. To achieve this, the programme has adopted a new strategy in RNTCP Phase III (2012–2017) of ‘universal access for quality diagnosis and treatment for all TB patients by engaging all health care providers’7. In order to achieve this objective, it will need to improve and expand its engagement with private sector providers. understand the dynamics of the private healthcare market holistically to arrive at optimal mechanisms of engaging PPs (WB-TB project unpublished data). Otherwise the efforts of controlling TB through RNTCP will go waste negating the gains made all these years. PPs are referring substantial number of TB suspects, even though there are no formal financial payments made to them. These data strongly indicate that systematic efforts by the Govt. to promote the engagement of PPs in RNTCP will yield dividends. The TB programme has to reexamine the ways of collaborating with PPs.

In full

279+94=373 and not 365. Revise the numbers.

?

Comment on Table: include GPs under the allopaths.