Bulletin of the World Health Organization

What we need more in India for TB control: more diagnosed patients or more cured patients?

Article: Lönnroth et al. 2004;82:580-586

The paper on Public–private mix for DOTS implementation by Knut Lönnroth et al. has tried to explore the possible model for the effective public-private mix for the DOTS implementation. To work on final model the researchers have compared 4 interventions at 4 different settings in 3 high TB burden developing countries (India, Kenya and Vietnam).

In the TB management it is proved that breaking the chain of infection is very crucial for reducing the burden of disease and reaching to a level where TB would not be major public health problem. To achieve this, it is essential to increase the patients access to high quality diagnostic and treatment facilities. But apart from this it is more important to have a very strong system so that every patient started on treatment should complete the treatment without fail and get cured. In the light of this premise, holding and ensuring DOTS is very crucial then increasing the diagnostic and treatment initiation. (The case of China is the latest example).

Taking this line if we review all 4 projects compared and model suggested in the research paper it does not present a clue as to how these models are addressing the very crucial issue of patient holding and ensuring DOTS? For example in the New Delhi study, after all the private system ultimately relies on the governmental system for default retrieval and for completion of treatment of those who are registered under DOTS. In the final analysis the paper emphasizes the fact that for the success of any such model a strong public health system is a prerequisite. A strong public system is essential to build a competent private sector and further a more sensible private system.

In India inability to hold the patient load and to provide quality and patient friendly public health services accessible to all by the government system is an important reason for the TB patients to seek treatment from private sector. In the light of this following are the some more possible suggestion to make this PPM model more effective.

There is a need to develop a specific strategy to equip the public sector for handling more number of referred cases from private providers, regular supply of PWBs to this increased number of the cases and also staff compatibility to handle increased number of recording and reporting procedures. Even if this is made available it is also necessary to ensure that the DOT is happening because:

  • Under the RNTCP the major challenge is to develop a strong network of the DOT providers.
  • As he (DOT provider) is the integral part of entire concept of DOTS, it is a major challenge for the success of DOTS to find a commited DOT provider for each and every patient.

A further model has to be developed in the line of any other (public-public, public-private or even private-private mix).

In my opinion a more workable model in a country like India would be:

Dr. Vandana Joshi MBBS, MPH (Sydney), DCH. State Program Manager, CARE-India-Madhya Pradesh. (email: vdjoshi@satyam.net.in)