Engaging private-sector providers to accelerate TB care and treatment

Tuberculosis (TB) is the sixth-leading cause of death in India and threatens the country’s rapidly growing urban communities. Nearly 80 percent of people with TB seek diagnosis and treatment from providers 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 underreporting of the number of TB cases.

There are also several gaps in private-sector TB treatment, such as delayed diagnosis, nonoptimal quality of care, lack of systems for tracking treatment adherence, and minimal patient support. These lead to a high rate of treatment dropout.

Alongside two community-based organizations, and with the support of the Bill & Melinda Gates Foundation, PATH supported the development of a pilot project called the Private Provider Interface Agency (PPIA) in Mumbai. It was designed to allow TB patients in the private sector to get access to free public-sector drugs and subsidized state-of-the-art TB diagnosis. By bringing to light the previously "invisible" TB patients in the private sector, this helped increase TB case notifications and treatment adherence and improve diagnostic services.

Taking a whole systems approach, PPIA worked with local community-based organizations to map and engage private providers, chemists, and diagnostic centers in 15 high-TB-burden wards across Mumbai.

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 patients to get the correct diagnosis and timely treatment. Private practitioners were given a list of diagnostic centers where they could send presumptive TB patients to get free World Health Organization (WHO)–approved diagnostic tests using PPIA vouchers. The agency also provided sample transportation services, so that patients did not need to travel to the testing labs. Upon confirmation of TB, the private practitioners generated a voucher that patients showed to chemists belonging to the PPIA network in order to receive 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 new digital tools, patients were also sent daily reminders via SMS, and a dedicated call center supported treatment adherence.

PPIA implemented a digital e-voucher system that offered three advantages: easy and quicker referrals, more robust patient tracking, and seamless payment and reimbursement. Easy referrals reduced administrative barriers to seeking care, supported high-quality service delivery, and incentivized private providers to comply. At the same time, the reimbursement mechanism removed the financial burden from the patient.

The unique digital patient-support tools developed for the PPIA model have been very effective as well, both for supporting patients and for providing critical data to decision-makers.

With these digital tools it became possible to capture events in a patient’s pathway from diagnosis until the end of treatment, which 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, providing data to support decision-making. This has led to these digital tools being included in the government notification systems for countrywide usage.

PPIA dramatically increased the rate of case notifications from private-sector providers in Mumbai: from 2 percent in 2013 to 47 percent in 2017. It resulted in more than 60,000 TB cases being diagnosed in Mumbai, more than 7,000 TB patients being screened for HIV, and a treatment success rate of over 80 percent.

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.

Based on the success achieved through the PPIA model in Mumbai, a large-scale, pan-India version called the JEET (Joint Effort for Elimination of Tuberculosis) project was created with the support of the Global Fund. With support from partners, the JEET project is being implemented by the Center for Health Research and Innovation (PATH’s India affiliate) and rolled out across India in stages. Within three years, JEET is projected to notify 1.6 million TB cases and ensure that at least 70 percent of the patients are successfully treated.

Other public health actions like universal drug sensitivity, HIV and diabetes testing, and nutrition incentives to patients are also now facilitated through the JEET project, improving community health overall.

PPIA strengthened the capacity of private providers serving the population-dense urban areas in Mumbai to ensure early, accurate diagnosis of TB, effective case management, and successful treatment for patients, thereby providing access to high-quality and affordable urban primary health services.

While focused on tuberculosis, this approach is purposefully aligned with key components of urban primary health care like multisectoral action, patient-friendly services, integration within health systems, and mobilized communities. Because of its primary health care–oriented foundations, PPIA offered a service delivery model to address a wider range of essential urban health services.

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