The other public health challenge

Written By Shibu Vijayan

Not so long ago, before the terms “COVID”, and “masking” entered popular parlance, the public health community in India was focused on ending another age-old obstacle to our well-being — by 2025 actually. When we came together as a country to draft the National Strategic Plan (NSP) to eliminate TB by 2025, we set ourselves a target of doing so five years ahead of what the Sustainable Development Goals committed.

Sweeping changes were envisaged to improve accessibility to and affordability of TB services, integrating novel technology solutions, and creating a unified health system, where the public and private sector would work together to offer quality services to all TB patients and achieve the elimination targets.

The private health sector in India serves as the first point of contact for over 60 per cent of TB patients in the country; engaging it has been crucial to detecting more cases (within six years, the programme saw a 223-fold jump in cases reported that now stand at 6.7 lakh) and providing appropriate and holistic care. This success was a result of a comprehensive regulatory framework that mandated and incentivised case notifications coupled with an innovative service delivery strategy, supported by an ever-improving IT platform (Nikshay). The service delivery strategy brought in intermediary NGOs to engage with private providers, and improved convergence between labs and pharmacists to make sample collection easier and enable door-step drug delivery. Through these interventions, the Centre created an ecosystem wherein private providers were able to provide patients with the best treatment with autonomy and collaborate with NTEP for fulfilling their public health responsibilities.

The first private sector engagement programmes were piloted in four cities across the country, through the Private Provider Interface Agencies (PPIA) models to develop a network of private providers, chemists, and labs to provide free TB care in the private sector to all. As part of the programme, a voucher system was initiated that connected different touch points (doctors, laboratories, and chemists) and aided patients in accessing care with minimal out-of-pocket expenditure. In these cities, private sector notifications rose by almost 400 per cent during the implementation of the program. Based on these results, the Centre expanded private sector engagement programs across the country initially through the JEET (Joint Effort for Elimination of TB) programme with the support of the Global Fund, and subsequently through domestic government funding.

The COVID-19 pandemic, however, has resulted in a delayed rollout of domestically funded private sector engagement programme. Prolonged lockdowns and the restriction of many hospitals for only COVID-19 services coupled with high fear among smaller private providers and stigma among patients, led to several challenges to the TB programme. Additionally, the diversion of staff — primarily lab technicians — led to a significant fall in TB case detection. The way to bring the TB programme back on track is through rapid and intensified private sector engagement. It is also critical to leverage the thriving innovations in the private health care sector and call for a unified approach to the governing health systems to ensure that both the public and private sector can contribute to a singular vision.

Private sector engagement requires that governments focus on governance of the entire health system – both private and public – to ensure quality care and financial protection of patients, irrespective of where they seek care. As part of this exercise, the programme could also look towards purchasing services as a payer through existing private facilities to further improve access and affordability of care. It is to be noted, that temporary partnerships between the public and private sector are not financially sustainable. It is critical for the programme (in co-ordination with the private sector) to develop strategies for long term engagement that improve financial viability. Not only would this promote a better response from the private sector for TB, but also COVID-19 and other essential services.

Given the demand for private sector service delivery, the health ministry, along with the NITI Aayog has begun to steward a mixed health system encompassing both the public and private sectors. The health ministry will govern the implementation of this mixed system by building consensus among all stakeholders on effective means and strategies to engage the private sector in health service delivery. In this scenario, it is also critical for the NTEP and the Ministry of Health and Family Welfare to encourage entrepreneurs and startups in the health sector and facilitate and finance hybrid models that encourage for-profit health organisations to collaborate with community-based organisations to improve care provision and provide support to patients. Not only will this leverage private sector capacities to empower community organisations for patient support and private sector efficiencies for logistics and project management, but also enable the health system to bridge the gap and respond to the potential surge in demand for healthcare if COVID-19 cases rise.

The last year has shown that even all-encompassing strategies can be undone instantly. To ensure we achieve our target of a TB-free India by 2025, the programme needs to further streamline and simplify coordination between the private and public sectors. By assigning responsibilities to providers without distinguishing between the public and private sector and establishing specific requirements (through a service delivery package) the program would improve the efficiency of TB elimination efforts and enable the health system to achieve the goal of a TB free India.

The writer is Global TB Technical Director, PATH

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