Public–private mix DOTS in India
The base paper highlights the challenge of maintaining the quality of TB services while working with multiple sectors, and this discussion is very relevant to the Indian setting. Despite having a large network of state government-owned public health facilities, a significant proportion of Indian patients seek health care from the private sector.1 Numerous nongovernmental organizations (NGOs) provide TB services. Moreover, many large and small state and national public-sector providers – including railways, social insurance, ports, mines and the armed forces – also manage large numbers of TB patients but are not under the direct purview of the Revised National TB Control Programme (RNTCP).
To address this, the RNTCP piloted and documented innovative public–private mix DOTS (PPM DOTS) models during the early phase of expansion. Evaluation of these models provided evidence for additional TB case detection with good treatment success rates.2 Subsequently, the RNTCP recognized PPM DOTS as a strategy to manage TB patients reporting to multiple sectors and different types of health-care providers. From as early as 2002, RNTCP had expanded PPM DOTS activities country-wide using the programme guidelines for involvement of NGOs and private practitioners.3,4 The strategy is built around developing a DOTS task mix for each provider type, with the RNTCP offering support for tasks that the relevant provider is unable to perform, such as defaulter retrieval or laboratory quality assurance. For medical college involvement, state-level and national task forces were created.
In 2003, the RNTCP launched intensified PPM DOTS activities in 14 urban districts. WHO-PPM medical consultants and peripheral field supervisors were recruited and posted to these districts. An expanded version of the existing routine RNTCP surveillance system collected disaggregated data from the different health-care providers. Providers were involved through a systematic process of situational analysis and listing of health-care facilities, sensitization and training of practitioners on RNTCP, training of RNTCP staff on PPM-DOTS, identification of facilities for RNTCP service delivery, memoranda of understanding and RNTCP service delivery.
The data from the intensified PPM sites have shown an overall increase in the number of TB cases notified under RNTCP. The state government public health departments remain the largest contributors to case detection, followed by medical colleges and the NGO sector. The yield of cases from the private sector to RNTCP has not been proportionate to the numbers involved. This is because there are numerous private clinics and hospitals in urban areas which usually have very low TB patient loads. NGOs and private practitioners contribute more to treatment observation than to case detection. These findings have highlighted and reinforced the importance of initially prioritizing and targeting PPM-DOTS activities for those facilities used by the largest numbers of patients. The intensified PPM-DOTS activities strengthened the wider government health sector’s involvement in the programme, leading to increased case detection from this sector.
Economic evaluations in Hyderabad, New Delhi and Bangalore show that PPM-DOTS is affordable and cost-effective, and that it reduces the financial burden on patients and society.5,6 Another evaluation in Bangalore shows that the intensified PPM initiative has predominantly reached people from lower socio-economic groups.7 Thus, although demanding in terms of efforts required, PPM DOTS is essential in the long-term interests of patients, providers and programmes.
Currently more than 12 000 private practitioners, over 2000 NGOs, over 230 medical colleges and 110 corporate-sector health facilities are involved in RNTCP activities. The Indian Medical Association is an important partner of RNTCP at national and state levels, and has adopted the International Standards for TB Care. As the base paper’s authors point out, RNTCP is aware that adopting standards alone may not lead to improved management practices. This will require continuous engagement and working in partnership with the diverse providers. Building on their achievements, the RNTCP and the Indian Medical Association are working together to implement the PPM component of a project recently approved by the Global Fund to Fight AIDS, Tuberculosis and Malaria. ■
- M Uplekar, S Juvekar, S Morankar, S Rangan, P Nunn. Tuberculosis patients and practitioners in private clinics in India. Int J Tuberc Lung Dis 1998; 2: 324-9.
- PK Dewan, SS Lal, K Lonnroth, F Wares, M Uplekar, S Sahu, et al. Improving tuberculosis control through public-private collaboration in India: literature review. BMJ 2006; 332: 574-8.
- Involvement of non-governmental organizations in the revised national tuberculosis control programme. Delhi: Central TB Division, Directorate General of Health Services, Ministry of Health and Family Welfare, Government of India; 2001.
- Involvement of private practitioners in the revised national tuberculosis control programme. Delhi: Central TB Division, Directorate General of Health Services, Ministry of Health and Family Welfare, Government of India; 2002.
- Cost and cost-effectiveness of public-private mix DOTS. Geneva: WHO; 2004 (WHO/HTM/TB/2004.337).
- A Pantoja, SS Lal, K Lonnroth, LS Chauhan, M Uplekar, MR Padma, et al. Cost and cost-effectiveness of scaled-up and intensive PPM DOTS in Bangalore. Int J Tuberc Lung Dis 2006; 10: S281-.
- KP Unnikrishnan, SS Lal, A Pantoja, K Lonnroth, LS Chauhan, R Jitendra, et al. Economic analysis of health care seeking behaviour by tuberculosis patients in Bangalore, India. Int J Tuberc Lung Dis 2006; 10: S281-.
- Central TB Division, Directorate General of Health Services, Nirman Bhavan, New Delhi 110 001 India.