India has the largest burden of tuberculosis (TB) and drug-resistant tuberculosis (DR-TB) in the world. An estimated 2.79 million people in India become ill with TB every year yet only 1.9 million TB cases are notified.
While the Revised National TB Control Program (RNTCP) of India provides TB services through the public healthcare sector, 60 percent of TB patients first seek care in the private sector. Inadequate coordination between the two healthcare sectors can lead to an array of challenges and delays for patients, potentially leading to a worsening of their disease, increased likelihood of transmission, greater out of pocket expenses, and loss of work time.
The Private Sector Engagement Project
This project was supported by a United Way World grant made possible by Eli Lilly and Company Foundation (Lilly Foundation) in collaboration with KNCV Tuberculosis Foundation and REACH, a local non-governmental organization (NGO) well known for working with the local private sector. The project was launched in Chennai, India in 2015.
Its goal was to build an evidence based public private collaboration model using an NGO as an interface agency to better leverage private sector engagement in TB care. The project evaluated interventions for the effective engagement of the private sector in diagnosing, notifying and ensuring early access to care for people with TB, using modern lab technologies and appropriate treatment regimens of quality-assured drugs in South and Central Chennai.
Since its introduction, the private-public model has proven to be not only successful but also a sustainable approach to TB diagnosis and treatment.
How the Model Works
Before the project began focus group discussions and one-to-one interviews were held with different type of providers to assess their needs. The project interventions were designed using the findings of this assessment. A technical advisory group of public and private medical professionals was formed to support the project throughout its implementation.
The next step of the public-private mix model (PPM) was to conduct individualized sensitization sessions for private practitioners who then enroll in the program. Once sensitized, private practitioners knowledgeable of the Indian Standards of TB Care, and they could refer their patients for free services such as chest x-rays, diagnostic Xpert test, and TB drugs using referral coupons.
Patients remained with their private healthcare providers and visited the nearest PPM centers within the network to receive the care needed throughout the entire treatment process, from sputum sampling to treatment completion. At these centers, the interface NGO provided additional patient-centered TB care such as counseling, home visits, contact investigations, nutritional and treatment adherence support. The NGO also supported the notification process and the recording of treatment outcomes.
Benefits and Results
The model reciprocally benefits all parties from TB patients, the private providers to the RNTCP.
TB patients can retain their private providers whom they trust, while receiving treatment free of charge via the RNTCP. The interface NGO provides them with access to supplemental services and support which in turn enhances their knowledge of TB, their treatment adherence and their outcomes.
On the other hand, private providers are able to offer free quality diagnostics for TB, daily regimen as per Standards for TB Care, patient follow-up support for improved treatment adherence, linkages for DR-TB patients to better-equipped RNTCP facilities, notification support via an online platform, and quality communication materials about TB for themselves and their patients.
The increased participation of the private sector means the RNTCP also improves notifications rates of TB cases, receives more referrals to their facilities for standard treatment as well as those for other facilities with expertise in DR-TB treatment. All these efforts serve to increase reporting of TB, treat more TB patients and disrupt the chain of transmission.
During the seven quarters of active project operations, the private sector referred 2,621 patients and diagnosed 1,232 TB cases in the Central and South districts of Chennai, approximately 13 percent of the total cases notified in these districts during the period. It’s unlikely that these cases would have been reported to the RNTCP without the project. Instead, they would have remained as part of the unreported, or “missing” cases.
57 percent of the 702 cases diagnosed as TB were bacteriologically confirmed using GeneXpert, a technology rarely used in the private sector prior to the project. This represents an increase in bacteriological confirmation of TB in the private sector, but improvement is still needed. Private providers continue to rely heavily on chest x-rays for diagnosis, and have few means of confirming extrapulmonary TB.
TB Model for Replication and Scaling Up
The participatory nature of the PPM model and its subsequent success demonstrates that the private sector can and must play a pivotal role in TB care and prevention. If appropriately replicated in other settings, the public-private mix model, with an NGO interface, is poised to bridge gaps between private providers, patients and public healthcare services. The model has already been adopted by the local city corporation and expanded to include all of Chennai as part of the TB Free Chennai Initiative.
Materials for the public-private mix model are available to view and download here at the KNCV Knowledge Center.
The materials include:
- Project EQUIP, description of the model (pdf)
- Video of The EQUIP Private-public Mix Model
- Video interviews with private providers & NGO Staff
- 3 Animated patient information videos
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This project was supported by a United Way World grant made possible by Eli Lilly and Company Foundation (Lilly Foundation).