Key lessons from public-private efforts will help us eliminate TB
PremiumWe must absorb learnings on training, tendering and financing for PPP programme implementation to achieve that goal
The covid pandemic has reminded us of the private sector’s disruptive potential for serving public health goals. However, in the past, central and state governments have strived to engage with the private sector in different disease areas. There are also several examples in maternal health; the Chiranjeevi Yojana programme in Gujarat, for instance, which was envisioned to increase institutional deliveries by working with private providers, reduced maternal mortality rates by more than half . The Hausala Sajheedari initiative effectively engaged private health facilities for family planning in Uttar Pradesh , where private providers could provide free family planning services on a reimbursement basis under a public private partnership (PPP) model.
Building on the learnings of such collaborations, we need to arrive at a holistic strategy that assimilates best practices for private sector engagement effectively, the aim being to identify engagement models with the private sector which can be scaled up across multiple disease areas.
In this context, tuberculosis (TB) is one public health issue that illustrates numerous challenges and also offers learnings about potential solutions that can mitigate not just TB, but other diseases as well. Almost half of all patients with TB symptoms seek care in the private sector. Here, the National Prevalence Survey can offer crucial insights because it offers disaggregated data about the actual burden of TB in India and health-seeking behaviours in the public and private sectors. This information can help form a tailored approach for TB elimination that can suit different state geographies within the country. At the same time, unstandardized care in the private sector could lead to treatment delays, contributing to the emergence of drug-resistant TB and increased mortality; a 2019 study estimated that a symptomatic patient approached multiple private healthcare providers, taking up to 65 days before an accurate diagnosis. The challenge can thus be summarized like this: How can public health systems capitalize upon the disruptive potential of the private sector’s reach and resources and ensure standardized care?
For TB, private sector engagement programmes have been implemented dating back to the 1990s. One highly effective model has been the Private-Provider Interface Agency (PPIA). Implemented in Mumbai in Maharashtra, Patna in Bihar and Mehsana in Gujarat, PPIAs worked with a network of private doctors, chemists, laboratories, and hospitals to ensure that TB diagnosis and treatment practices adhere to the prescribed ‘Standards of TB Care’ in India. As a result, between 2014 and 2018, in Mumbai and Patna, there was a 351% and 532% increase in TB case notifications from the private sector. This was vital because actual reporting of cases result in greater understanding of the TB burden on the ground. Soon, the government expanded this PPP model to develop what we now know as the Patient-Provider Support Agency (PPSA) model.
The government’s annual TB report tells us that PPSA programmes have now been scaled up and launched in more than 170 districts across India, but much more needs to be done to ensure seamless implementation across India.
Domain experts have already identified some key challenges. First, because it’s a new approach, state and district administration and programme implementers will need to be convinced and encouraged to support and implement this initiative across their region. It will be vital in building their capacity and undertaking hand-holding exercises for programme implementers at the state and district levels. For this, state technical support units (STSUs) have already been established in some states.
Second, the tendering process should be expanded and advertised to allow diverse organizations in this segment to apply for consideration as PPSAs. At this point, very few non-government organizations (NGOs) end up applying because information on such contracting isn’t easily visible or is difficult to understand. Expanding the dissemination of such Requests for Proposals (contracting calls for bidders) and choosing relevant dissemination platforms might help.
Third, it will be useful to explore opportunities for output-based financing for PPSAs. This approach, which rewards individuals or institutions (in this case, PPSAs) after agreed-upon results are achieved and verified, can help assuage all stakeholders’ concerns. Care must be taken, though, to deploy this model in a well considered manner. The metrics for payments to PPSAs—from ensuring notifications to conducting advanced diagnostic tests, HIV-diabetes testing, etc—may need to be calibrated from state to state by their varying requirements, considering how different geographies can present different on-ground scenarios.
Linkages can be explored with existing government initiatives such as the flagship Pradhan Mantri Jan Arogya Yojana (PM-JAY), which aims to provide health cover of ₹5 lakh per family per year for secondary and tertiary care hospitalization. Especially when it comes to more difficult-to-treat forms of TB, such as extra-pulmonary TB, the in-patient care services can be very steep. Therefore, including a TB care package in PM-JAY can augment the scheme’s utility for the common citizen.
Finally, it is profoundly encouraging to see the government introduce flagship programmes such as the Ayushman Bharat Digital Mission (ABDM), which aims to digitize the country’s healthcare ecosystem and thereby enable the creation of an enabling ecosystem for fostering public-private collaborations. Such initiatives will undoubtedly help eliminate TB in India by 2025. Such efforts will ensure the country will keep up rapid progress towards achieving universal health coverage and quality healthcare for all.
Vijayshree Yellappa is chair of the executive committee, TBPPM-Learning Network, India Chapter.
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