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Finding the missing millions: the importance of private sector engagement for eliminating tuberculosis

January 16, 2019 by Dr. Shibu Vijayan

A narrow lane inside a slum in the city of Mumbai, India. The densely crowded slums are home to many tuberculosis patients.

A narrow lane inside a slum in the city of Mumbai, India. The densely crowded slums are home to many tuberculosis patients who often do not complete the full treatment. Photo: PATH/Prashant Vishwanathan

The PPIA model implemented by PATH and partners in Mumbai has resulted in more than 60,000 TB cases being diagnosed, over 7,000 TB patients being screened for HIV, and achieved an over 80% treatment success rate. A pan-India version of this model is projected to impact 3.5 million lives across 23 states and 406 cities in the next three years.

Confronting the world's highest burden of MDR-TB

India is currently home to more tuberculosis (TB) cases than any other country in the world, 2.7 million cases according to one estimate. TB is curable if a patient takes drugs as per schedule. But many do not follow the prescribed treatment regimen or drop out entirely and end up being infected by TB multiple times. This leads to drug resistance building up. As a result, India also has the highest burden of multi drug resistant TB (MDR-TB) with an estimated 135,000 cases annually. MDR-TB needs an expensive and extended treatment regimen that has severe side effects.

The government of India has committed to eliminate TB by 2025. For this, the government provides free TB drugs to patients and has also made it mandatory for the cases to be notified so that they can be tracked through the government’s monitoring system: Nikshay.

Dr. Prakash Khaitani checks a patient who have come for tuberculosis treatment in S.N. Maternity and General Hospital in Govandi slum area in Mumbai, India. Photo: PATH/Prashanth Vishwanathan

Dr. Prakash Khaitani, a private provider, checks a patient who has come for tuberculosis treatment in a hospital in the Govandi slum area of Mumbai, India. Photo: PATH/Prashanth Vishwanathan

The importance of engaging the private sector

However, more than 70% of TB patients in India seek diagnosis and treatment in the private sector. The diagnosis and TB treatment status of patients in the private sector is not recorded or notified in government information systems. This causes under reporting of the number of TB cases, which can lead to low treatment adherence. It is estimated that there are more than a million missing TB cases in India. In addition, a close analysis of the patient care cascade found many gaps in private sector TB treatment such as:

  • delayed diagnosis
  • less than optimal quality of care
  • wrong diagnostic and treatment protocols being used
  • ineffective and varying drug regimens leading to unsuccessful treatment of TB
  • financial burden due to high out of pocket expenditure
  • lack of systems for treatment adherence as well as minimal patient support leading to a high rate of treatment drop-out

TB is a highly contagious infection. Even if a single patient drops out before completing treatment, he or she risks the lives of many around them, especially when they live in densely crowded slums where nutrition levels tend to be low.

Public sector vs private sector TB treatment

Given so many gaps in seeking quality TB treatment from the private sector, why do so many patients still opt for treatment away from the public sector? One key reason is that decades of low investment in public health systems has led to understaffed and overburdened public sector hospitals.

According to the WHO, India ranks 52 out of 57 in a list of countries facing a human resource crisis in public health facilities.

Private healthcare facilities are able to offer far greater variety in the quality of care. Patients get to see a doctor without waiting endlessly, something which for example may cost a daily wager his or her entire day’s pay if accessing a government health facility. In addition, private healthcare providers or facilities are co-located with the communities seeking healthcare, reducing transport time and expenses. The Government of India therefore identified private sector engagement as a key driver in national efforts to notify, treat and eliminate TB.

Fighting TB with PPIA

The government of India, WHO and PATH began the unique Private Provider Interface Agency (PPIA) model, aimed at engaging TB patients within the private sector. The model was first established in Mumbai with initial support from the Bill & Melinda Gates Foundation. It was designed to allow TB patients in the private sector get access to free public sector drugs and subsidised state of the art TB diagnosis. By bringing to light the previously ‘invisible’ TB patients in the private sector, this would help with increased TB case notifications, treatment adherence and improved diagnostic services.

The PPIA model was launched in 2014 and first mapped out 15 high burden TB wards across Mumbai. After this, private doctors, chemists and diagnostic centres in those locations were engaged and onboarded in the PPIA program.

Prior to PPIA, patients had to go through a tedious process to get a TB test and follow up report. The PPIA model made it much easier for the patient to get the correct diagnosis and timely treatment. Private practitioners were given a list of diagnostic centres where they could send presumptive TB patients to get free WHO approved diagnostic tests using PPIA vouchers. This model also provided sample transportation services, so that patients did not need to travel to the testing labs. Upon confirmation of TB, the private practitioners would generate a voucher that patients showed to chemists belonging to the PPIA network to get medicines free of cost. These chemists were later compensated by PATH. In addition to free tests, patients also received regular support from field officers who motivated them to continue with the treatment. By leveraging Information, Communication and Technology (ICT) tools, patients were also sent daily reminders via SMS and through a dedicated call centre for ensuring treatment adherence.

A doctor fills out a PPIA chest X-Ray voucher for a patient who has come for tuberculosis treatment in Mumbai, India. Photo: PATH/Prashant Vishwanathan

A doctor fills out a PPIA chest X-ray voucher for a tuberculosis patient in Mumbai, India. Photo: PATH/Prashant Vishwanathan

As a result of all these efforts, the patient centric PPIA model became a huge success. It resulted in more than 60,000 TB cases being diagnosed in Mumbai, over 7,000 TB patients being screened for HIV, and achieved an over 80% treatment success rate. Currently, the PPIA model is being integrated into Mumbai government’s TB control program for long term sustainability.

The uniqueness of the ICT tools developed and used in this model have been very effective as well. For example, it was possible to capture events in a patient’s pathway till the end of treatment which when aggregated would provide population level insights into treatment adherence. The tools also enabled quicker entry of case notifications from the private sector into public sector health systems. This has led to these ICT tools be included in the government notification systems for countrywide usage.

The Government of India and WHO did a costing analysis of the PPIA intervention and found that the expense of engaging the private sector for TB case diagnosis and notification is similar to the cost in the public sector indicating that this is a cost-efficient model that can be scaled up through public health systems. The Government of India is now taking this model ahead in other parts of the country through the Private Provider Support Agency model.

PPIA goes national and international

Based on the success achieved through the PPIA model in Mumbai, a large scale, pan-India version called the JEET (Joint Effort to Eliminate Tuberculosis) project has been created with the support of The Global Fund to Fight AIDS, Tuberculosis and Malaria. The JEET project is being implemented by the Center for Health Research and Innovation (PATH’s India affiliate) in partnership with William J Clinton Foundation and FIND and is currently being rolled out across the country in stages. Within 3 years, JEET is projected to impact 3.5 million lives across 23 states and 406 cities.

The PPIA model has also gained much recognition nationally and internationally. It received the prestigious Porter Prize in 2018 and was showcased at the first ever UN General Assembly high level meeting on TB.

Going forward, PATH and other partners are piloting the use of the PPIA model to tackle other critical diseases such as hypertension to enable better linkages between the public and private healthcare sectors so that patients get access to affordable, accurate and timely treatment which will enable them to lead healthy and productive lives.

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