Private sector involvement envisaged in the National Strategic Plan for Tuberculosis Elimination 2017–2025: Can Tuberculosis Health Action Learning Initiative model act as a road map?

Abstract

Tuberculosis (TB), one of the oldest diseases known to mankind has become a notifiable disease. Public private mixes guidelines for TB programme managers had already been published by Central TB Division in the Ministry of Health and Family Welfare. One of the tremendous challenges that impede private sector involvement in TB care is delayed diagnosis, treatment of variable quality, surveillance, adherence monitoring, contact investigation, and outcome recording. The present article has addressed the involvement of the private sector with special emphasis on Tuberculosis Health Action Learning Initiative (THALI) model. The key elements of THALI being: (1) Identifying and scaling up of innovative approaches to improve the quality of private sector diagnosis, referral, and treatment of TB, (2) Strengthening the utilization of TB resources of the respective municipalities, (3) Testing of upcoming technological innovations, and (4) Improving data for evidence-based decision making. Nevertheless, sustainable parallel implementation framework adopting the strategies of THALI Model, along with prior Geographic Information System mapping of private health facilities e.g. hospitals/nursing homes, private providers, diagnostic centres, pharmacies etc. should be in place so as to correctly implement the slogan – “Unite to end TB: Leave no one behind”.

Introduction

Tuberculosis (TB) has been known to mankind since ancient times, and the disease was first formally described by Greek physician Hippocrates, who is regarded as the Father of Medicine. Since 1882, when the tubercle bacillus was first discovered by Robert Koch, herculean efforts have been made to control this killer disease, but still at present, TB is one of the top 10 causes of death worldwide. In 2015, 10.4 million people fell ill with TB and 1.8 million died from the disease. Six countries account for 60% of the total, with India leading the count (21%), followed by Indonesia, China, Nigeria, Pakistan and South Africa. Nearly one in every four patients with TB in the world is an Indian.¹ More than 600 people die from this disease in India every day according to the TB Annual Report 2016.² India also has the highest burden of multidrug-resistant TB (MDR-TB) in the world.³ Although India has a robust programme, i.e., Revised National Tuberculosis Control Programme (RNTCP), treating more than 10 million patients with TB, the rate of decline of new reported cases (estimated incidence of new TB cases per year) is 2.8 million cases in 2015, which is too slow to meet the 2030 Sustainable Development Goals and 2035 End TB targets.^{1, 3, 4} The present article has addressed the involvement of the private sector as envisaged in the National Strategic Plan for Tuberculosis Elimination 2017–2025, with special emphasis on Tuberculosis Health Action Learning Initiative (THALI) model.

Tuberculosis Health Action Learning Initiative (THALI) model

A model framework named as THALI is a United States Agency for International Development initiative, with an investment of $22.5 million, started in 2015 in collaboration with Central Tuberculosis Division, Government of India. Its role is to complement RNTCP by engaging municipal governments and private health-care providers to prevent, test and treat TB in select cities in India such as Kolkata, Bangalore, Hyderabad, Chennai and Pune, with special emphasis on urban slum communities.^{5, 6, 7} In Bangalore, Karnataka and Hyderabad, the implementing agency is Karnataka Health Promotion Trust, whereas in West Bengal, World Health Partners, Global Health Strategies, John Snow India and other partners have agreed to contribute to this project through their specific domains of expertise.⁸

Tuberculosis Health Action Learning Initiative (THALI) components

In the private sector, patients with TB receive multiple regimens with minimal follow-up, and notification rate is also very low, which is one of the important pillars of controlling TB, as rightly pointed out by Dr. Robert Koch in his Nobel Lecture in 1905.⁹ In this initiative, more emphasis has been given to improve TB notification rate, particularly from the private sector. The following are the key elements of THALI: (1) identifying and scaling up innovative approaches to improve the quality of private sector diagnosis, referral and treatment of TB, through adherence to the recently released “Standards for TB Care in India”, (2) strengthening the utilization of TB resources of the respective municipalities, (3) testing upcoming technological innovations and (4) improving data for evidence-based decision-making.^{5, 6}

Tuberculosis Health Action Learning Initiative (THALI) network

In THALI Network, a private physician, who has already registered with this initiative by signing a memorandum of understanding (where in a unique identification number is provided to the physician), will notify a case by giving a missed phone call to call centre number (09211766888). Very shortly, the physician receives a phone call, and the details of the patient with TB/suspect case such as name, age, sex, religion, address, type of cases and treatment initiated are recorded, after which patient case ID and voucher ID are provided to the physician, which he has to note and write down in the prescription of the patient. On showing this prescription with the voucher number, the patient will get free diagnostic facilities and 1st-line medicines at designated outlets throughout the treatment until outcome is declared. In addition, the patient is followed up for a long term after completion of the treatment as per the Standards for TB Care in India (STCI), and if necessary, referral to Government GeneXpert laboratories is given. GeneXpert test is a molecular TB test conducted in sputum sample which detects the DNA in TB bacteria. In addition, it can also detect the genetic mutations associated with rifampicin resistance. Results are obtained very fast in less than 2 h.¹⁰ There is also provision for small monetary incentives to the doctors to encourage the private healthcare network. Thus, THALI model is designed to provide seamless access to high-quality TB diagnosis and treatment services catered by the private health sector, especially for vulnerable populations. But, partial geographic coverage under this initiative and restricted resources in a time-bound framework of 4 years are some of the limitations. Performance evaluation report is also needed in due course to further improve the operational strategies of the initiative.

Role of the private sector in Tuberculosis (TB)

In India, the private health sector is very extensively organised and provides for a major proportion, possibly more than half of the health care.¹¹ The same is being true in providing TB care also; private health-care providers play an important role in providing health-care services to majority of the patients with TB.¹² Sometimes, the private sector is the first source of contact for most patients with TB in developing countries such as India. Then, it was realized that TB control would not be possible without active involvement of the private sector. Subsequently, public–private mix guidelines for TB programme managers had already been published by the Central TB Division in the Ministry of Health and Family Welfare.¹³

Challenges of the private sector in Tuberculosis (TB) care

One of the tremendous challenges that impede private sector involvement in TB care is delayed diagnosis and treatment of variable quality, particularly among patients seeking care from private health-care providers, who alone are ill-equipped to sustain their patients on prolonged, costly treatment, thus adding to the emerging burden of MDR-TB and extensively drug-resistant TB.^{4, 12, 14, 15} Although the STCI, mandatory TB notification, NIKSHAY, etc. are among the existing tools to improve TB care services in the private sector, quality services as assured in public health services such as surveillance, adherence monitoring, contact investigation and outcome recording rarely reach patients with TB who are privately treated.^{2, 3} The Government of India has introduced a system called NIKSHAY to keep a track of the patients with tuberculosis across the country. The word NIKSHAY is a combination of two Hindi words NI and KSHAY, meaning eradication of tuberculosis. NIKSHAY (www.nikshay.gov.in) is a Web-enabled application and has been in operation since June 2012.¹⁶ Moreover, absence of a definitive policy for private sector engagement and uptake of RNTCP public–private partnership schemes remains very low despite the structured national guidelines for partnership since 2002.¹⁷ Although funding partners and donors are increasingly investing and focussing on private sector engagement, their goals and strategies are not aligned with national priorities. All these loopholes have been identified in the National Strategic Plan for Tuberculosis Elimination 2017–2025, which has envisaged systematically to engage private health-care providers and provide programmatic support for better outcomes related to access, notifications, adherence, treatment outcomes and cost savings. The vision is to increase notification rate by private health-care providers from 0.2 to 2 million annually by 2020.⁴ Although challenges have been identified, implementation framework that outlines interventions for collaborating with the private sector and allocates resources to support its execution is yet to be chalked out. Isolated efforts of monetarily incentivizing private physicians for notification, streamlining treatment as per RNTCP protocol and ensuring adherence may not be a sustainable effort.

Conclusion

Nevertheless, sustainable parallel implementation framework adopting the strategies of THALI model, along with prior Geographic Information System mapping of private health facilities, e.g., hospitals/nursing homes, private health-care providers, diagnostic centres, pharmacies etc., should be in place. These will ensure full coverage of this sector, and efficient microplanning at each step would help strategies regarding private sector involvement as envisaged in the National Strategic Plan 2017. Thus, overall, the TB burden will be reduced along with fewer emergences of MDR cases. Thus, THALI model may be adapted as a road map to private sector involvement to achieve TB-free India so as to correctly implement the slogan “Unite to end TB: Leave no one behind”.

Conflicts of interest

The authors have none to declare.