Private Practitioners’ Perspectives on Their Involvement With the Tuberculosis Control Programme in a Southern Indian State

Document Type: Original Article

Authors

1 Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, UK

2 The Maharashtra Association of Anthropological Sciences, Centre for Health Research and Development (MAAS-CHRD), Savitribai Phule Pune University, Pune, India

3 Public Health Foundation of India, New Delhi, India

4 Departments of Clinical Research and Global Health and Development, London School of Hygiene and Tropical Medicine, London, UK

Abstract

Background
Public and private health sectors both play a crucial role in the health systems of low- and middleincome countries (LMICs). The tuberculosis (TB) control strategy in India encourages the public sector to actively partner with private practitioners (PPs) to improve the quality of front line service delivery. However, ensuring effective and sustainable involvement of PPs constitutes a major challenge. This paper reports the findings from an empirical study focusing on the perspectives and experiences of PPs towards their involvement in TB control programme in India.
 
Methods
The study was carried out between November 2010 and December 2011 in a district of a Southern Indian State and utilised qualitative methodologies, combining observations and in-depth interviews with 21 PPs from different medical systems. The collected data was coded and analysed using thematic analysis.
 
Results
PPs perceived themselves to be crucial healthcare providers, with different roles within the public-private mix (PPM) TB policy. Despite this, PPs felt neglected and undervalued in the actual process of implementation of the PPM-TB policy. The entire process was considered to be government driven and their professional skills and knowledge of different medical systems remained unrecognised at the policy level, and weakened their relationship and bond with the policy and with the programme. PPs had contrasting perceptions about the different components of the TB programme that demonstrated the public sector’s dominance in the overall implementation of the DOTS strategy. Although PPs felt responsible for their TB patients, they found it difficult to perceive themselves as ‘partners with the TB programme.’
 
Conclusion
Public-private partnerships (PPPs) are increasingly utilized as a public health strategy to strengthen health systems. These policies will fail if the concerns of the PPs are neglected. To ensure their long-term involvement in the programme the abilities of PPs and the important perspectives from other Indian medical systems need to be recognised and supported.

Keywords

Main Subjects


"Watch the Video Summary"

  1. Berendes S, Heywood P, Oliver S, Garner P. Quality of private and public ambulatory health care in low and middle income countries: systematic review of comparative studies. PLoS Med. 2011;8(4):e1000433. doi:10.1371/journal.pmed.1000433
  2. Konde-Lule J, Gitta SN, Lindfors A, Okuonzi S, Onama VO, Forsberg BC. Private and public health care in rural areas of Uganda. BMC Int Health Hum Rights. 2010;10:29. doi:10.1186/1472-698x-10-29
  3. Ha NT, Berman P, Larsen U. Household utilization and expenditure on private and public health services in Vietnam. Health Policy Plan. 2002;17(1):61-70.
  4. Wang Y. Public-Private Partnerships in the Social Sector: Issues and  Country Experiences in Asia and the Pacific. Vol ADBI Policy Paper No. 1. Tokyo: Asian Development Bank Institute; 2000.
  5. Raman AV, Björkman JW. Public-Private Partnerships in Health Care in India: Lessons for developing countries. Taylor & Francis; 2008.
  6. Bennett S, Hygiene LS. The Mystique of Markets: Public and Private Health Care in Developing Countries. London: Department of Public Health & Policy, London School of Hygiene & Tropical Medicine; 1991.
  7. Brugha R, Zwi A. Improving the quality of private sector delivery of public health services: challenges and strategies. Health Policy Plan. 1998;13(2):107-120.
  8. Uplekar MW. Private health care. Soc Sci Med. 2000;51(6):897-904.
  9. Mills A, Brugha R, Hanson K, McPake B. What can be done about the private health sector in low-income countries? World Hosp Health Serv. 2002;38(3):24-30.
  10. Berman P, Laura R. The role of private providers in maternal and child health and family planning services in developing countries. Health Policy Plan. 1996;11(2):142-155.
  11. Berman P. Getting more from private health care in poor countries: a missed opportunity. Int J Qual Health Care. 2001;13(4):279-280.
  12. World Health Organization (WHO). WHO Assembly Resolution: Strengthening the capacity of governments to constructively engage the private sector in providing essential health-care services. 63rd World Health Assembly, A63/25. Geneva: World Health Organization; 2010.
  13. International Institute For Population Sciences (IIPS). National Family Health Survey (NFHS-3), 2005–06. India Mumbai: IIPS and Macro International; 2007.
  14. Central Bureau of Health Intelligence (CBHI). Human Resource in Health Sector - National Health Profile (NHP) of India. http://www.cbhidghs.nic.in/index2.asp?slid=1256&sublinkid=1163. Accessed February 19, 2014. Published 2012.
  15. Reddy KS, Patel V, Jha P, Paul VK, Kumar AK, Dandona L. Towards achievement of universal health care in India by 2020: a call to action. Lancet. 2011;377(9767):760-768. doi:10.1016/s0140-6736(10)61960-5
  16. Sachdeva KS, Kumar A, Dewan P, Kumar A, Satyanarayana S. New vision for Revised National Tuberculosis Control Programme (RNTCP): universal access - "reaching the un-reached." Indian J Med Res. 2012;135(5):690-694.
  17. Ministry of Health and Family Welfare (MOHFW). Universal access to TB Care- A practical guide for programme managers. New Delhi: Central Tuberculosis Division, Directorate General of Health Services; 2010.
  18. Uplekar M. Place of PPM in the post-2015 TB strategy. http://www.who.int/tb/careproviders/ppm/PPM_post_2015_Strategy.pdf. Published 2013.
  19. Revankar CR. Public-private partnership in public health programmes in India. Health Administrator. 2008;21(1-2):24-25.
  20. Wells WA, Uplekar M, Pai M. Achieving systemic and scalable private sector engagement in tuberculosis care and prevention in Asia. PLoS Med. 2015;12(6):e1001842. doi:10.1371/journal.pmed.1001842
  21. World Health Organization (WHO). Global Tuberculosis Report 2013. Geneva: WHO; 2013.
  22. World Health Organization (WHO). Global Tuberculosis Report 2010. Geneva: WHO; 2010.
  23. Ministry of Health and Family Welfare (MOHFW). TB INDIA 2013 RNTCP Status Report. New Delhi: Central TB Division, MOHFW; 2013.
  24. Kumar P. Journey of tuberculosis control movement in India: National Tuberculosis Programme to revised National Tuberculosis Control Programme. Indian Journal of Tuberculosis. 2005;52:63-71.
  25. Khatri GR, Frieden TR. Controlling tuberculosis in India. N Engl J Med. 2002;347(18):1420-1425. doi:10.1056/NEJMsa020098
  26. Ministry of Health and Family Welfare (MOHFW). TB INDIA 2011 RNTCP Status Report. New Delhi: Central TB Division, MOHFW; 2011.
  27. World Health Organization (WHO). Involving Private Practitioners in Tuberculosis Control: Issues, interventions, and emerging policy framework. Geneva: WHO;  2001.
  28. Uplekar M, Juvekar S, Morankar S, Rangan S, Nunn P. Tuberculosis patients and practitioners in private clinics in India. Int J Tuberc Lung Dis. 1998;2(4):324-329.
  29. Department For International Development (DFID). Summary Report: Health Care Provider Survey in Andhra Pradesh, India. Impact Assessment for HIV/STI Prevention Programmes: Baseline Report Series. Andhra Pradesh: Department For International Development (DFID), AP State AIDS Control Society (APSACS) and Family Health International (FHI); 2001.
  30. MAAS. Can the Private and Public Sectors Collaborate for Effective Management of TB, HIV and Co-infection? A Situational Analysis in Hyderabad City, Andhra Pradesh. http://www.lshtm.ac.uk/dfid/targets/HIV-TB-PPM-Situation-Analysis-MAAS-CHRD-Dissemination%20Flyer.pdf. Accessed January 20, 2008. Published 2007.
  31. Uplekar MW, Rangan S. Private doctors and tuberculosis control in India. Tuber Lung Dis. 1993;74(5):332-337.
  32. Uplekar MW, Shepard DS. Treatment of tuberculosis by private general practitioners in India. Tubercle. 1991;72(4):284-290.
  33. Prasad R, Nautiyal RG, Mukherji PK, Jain A, Singh K, Ahuja RC. Treatment of new pulmonary tuberculosis patients: what do allopathic doctors do in India? Int J Tuberc Lung Dis. 2002;6(10):895-902.
  34. Singla N, Sharma PP, Singla R, Jain RC. Survey of knowledge, attitudes and practices for tuberculosis among general practitioners in Delhi, India. Int J Tuberc Lung Dis. 1998;2(5):384-389.
  35. Kelkar-Khambete A, Kielmann K, Pawar S, et al. India's Revised National Tuberculosis Control Programme: looking beyond detection and cure. Int J Tuberc Lung Dis.. 2008;12(1):87-92.
  36. Atre SR, Mistry NF. Multidrug-resistant tuberculosis (MDR-TB) in India: an attempt to link biosocial determinants. J Public Health Policy. 2005;26(1):96-114.
  37. Udwadia ZF, Pinto LM, Uplekar MW. Tuberculosis management by private practitioners in Mumbai, India: has anything changed in two decades? PLoS One. 2010;5(8):e12023. doi:10.1371/journal.pone.0012023
  38. Sheikh K, Porter J, Kielmann K, Rangan S. Public-private partnerships for equity of access to care for tuberculosis and HIV/AIDS: lessons from Pune, India. Trans R Soc Trop Med Hyg. 2006;100(4):312-320. doi:10.1016/j.trstmh.2005.04.023
  39. Bhat R. Regulation of the private health sector in India. Int  J Health Plan Manage. 1996;11(3):253-274.
  40. Fochsen G, Deshpande K, Diwan V, Mishra A, Diwan VK, Thorson A. Health care seeking among individuals with cough and tuberculosis: a population-based study from rural India. Int J Tuberc Lung Dis. 2006;10(9):995-1000.
  41. World Health Organisation (WHO). Informal consultation on private practitioners involvement in control of communicable diseases with a focus on tuberculosis. Geneva: WHO; 2000.
  42. World Health Organisation (WHO). Public-private mix for DOTS: report of the second meeting of the PPM subgroup for DOTS expansion. Geneva: WHO; 2004.
  43. Chauhan LS. Public-private mix DOTS in India. Bull World Health Organ. 2007;85(5):399-399.
  44. Ministry of Health and Family Welfare (MOHFW). Involvement of non-governmental organizations in the Revised National Tuberculosis Control Programme. New Delhi: Central TB Division, MOHFW; 2001.
  45. Ministry of Health and Family Welfare (MOHFW). Involvement of Private Practitioners in the Revised National Tuberculosis Control Programme. New Delhi: Central TB Division, MOHFW; 2002.
  46. Agarwal SP, Sehgal S, Lal SS. Public-Private Mix in the Revised National TB Control Programme. In: Agarwal SP, Chauhan LS, eds. Tuberculosis Control in India. India: Directorate General of Health Services, Ministry of Health and Family Welfare; 2005.
  47. Murthy KJ, Frieden TR, Yazdani A, Hreshikesh P. Public-private partnership in tuberculosis control: experience in Hyderabad, India. Int J Tuberc Lung Dis. 2001;5(4):354-359.
  48. Uplekar M, Lönnroth K. Engaging Private Providers in Tuberculosis Control: Public-Private Mix for DOTS. In: Raviglione MC, ed. Reichman and Hershfield's Tuberculosis: A Comprehensive, International Approach. New York: Taylor & Francis; 2006.
  49. Dewan PK, Lal SS, Lonnroth K, et al. Improving tuberculosis control through public-private collaboration in India: literature review. BMJ. 2006;332(7541):574-578.
  50. Engel N, van Lente H. Organisational innovation and control practices: the case of public–private mix in tuberculosis control in India. Soc Health Illn. 2013:1-15. doi:10.1111/1467-9566.12125
  51. Ministry of Health and Family Welfare (MOHFW). TB INDIA 2010 RNTCP Status Report. New Delhi: Central TB Division, MOHFW; 2010.
  52. Ministry of Health and Family Welfare (MOHFW). Revised Schemes for NGOs and Private Providers New Delhi: Central TB Division, MOHFW; 2008.
  53. Sahu S, Chauhan LS. The Role of WHO in the Successful Implementation and Expansion of the DOTS Programme in India. In: Agarwal SP, Chauhan LS, eds. Tuberculosis Control in India. India: Directorate General of Health Services, Ministry of Health and Family Welfare; 2005.
  54. Frieden TR, Khatri GR. Impact of national consultants on successful expansion of effective tuberculosis control in India. Int J Tuberc Lung Dis. 2003;7(9):837-841.
  55. Ministry of Health and Family Welfare (MOHFW). TB INDIA 2009 RNTCP Status Report. New Delhi: Central TB Division, MOHFW; 2009.
  56. Lal SS, Sahu S, Wares F, Lonnroth K, Chauhan LS, Uplekar M. Intensified scale-up of public-private mix: a systems approach to tuberculosis care and control in India. Int J Tuberc Lung Dis. 2011;15(1):97-104.
  57. Ministry of Health and Family Welfare (MOHFW). TB INDIA 2006 RNTCP Status Report. New Delhi: Central TB Division, MOHFW; 2006.
  58. Ministry of Health and Family Welfare (MOHFW). TB INDIA 2007 RNTCP Status Report. New Delhi: Central TB Division, MOHFW; 2007.
  59. Ministry of Health and Family Welfare (MOHFW). TB INDIA 2008 RNTCP Status Report. New Delhi: Central TB Division, MOHFW; 2008.
  60. Ministry of Health and Family Welfare (MOHFW). TB INDIA 2012 RNTCP Status Report. New Delhi: Central TB Division, MOHFW; 2012.
  61. Goenka S. Collaboration or communication with private providers? Conclusions based on insufficient evidence. BMJ2006;332:574.
  62. Mahendradhata Y, Lambert ML, Boelaert M, Van der Stuyft P. Engaging the private sector for tuberculosis control: much advocacy on a meagre evidence base. Trop Med Int Health. 2007;12(3):315-316. doi:10.1111/j.1365-3156.2007.01816.x
  63. Ministry of Health and Family Welfare (MOHFW). TB INDIA 2014 RNTCP Status Report. New Delhi: Central TB Division, MOHFW; 2014.
  64. Reeves S, Kuper A, Hodges BD. Qualitative research methodologies: ethnography. BMJ. 2008;337. doi:10.1136/bmj.a1020
  65. Bernard HR, Bernard HR. Research Methods in Anthropology: Qualitative and Quantitative Approaches. AltaMira Press; 2006.
  66. Guest G, MacQueen KM, Namey EE. Applied Thematic Analysis. SAGE Publications; 2011.
  67. Charmaz K. Constructing Grounded Theory: A Practical Guide Through Qualitative Analysis. SAGE Publications; 2006.
  68. Atun RA, Baeza J, Drobniewski F, Levicheva V, Coker RJ. Implementing WHO DOTS strategy in the Russian Federation: stakeholder attitudes. Health Policy. 2005;74(2):122-132.
  69. Ministry of Health and Family Welfare (MOHFW). Training Module for Medical Practitioners. New Delhi: Central TB Division, MOHFW; 2010.
  70. Starr P. The Social Transformation of American Medicine: The Rise of a Sovereign Profession and the Making of a Vast Industry. New York: Basic Books; 1982.
  71. Halpern SA. Medical authority and the culture of rights. J Health Polit Policy Law. 2004;29(4-5):835-852. doi:10.1215/03616878-29-4-5-835
  72. Desikan P. Sputum smear microscopy in tuberculosis: Is it still relevant? Indian J Med Res. 2013;137(3):442-444.
  73. Duanmu HJ, Zheng SH, Xu B, Fu CW. Improved case finding by using sputum examination in pulmonary tuberculosis suspects with clinical symptoms (Chinese). Zhonghua Jie He He Hu Xi Za Zhi. 2005;28(7):468-471.
  74. Bawri S, Ali S, Phukan C, Tayal B, Baruwa P. A study of sputum conversion in new smear positive pulmonary tuberculosis cases at the monthly intervals of 1, 2 & 3 month under directly observed treatment, short course (dots) regimen. Lung India. 2008;25(3):118-123. doi:10.4103/0970-2113.44122
  75. Puri L, Oghor C, Denkinger CM, Pai M. Xpert MTB/RIF for tuberculosis testing: access and price in highly privatised health markets. Lancet Glob Health. 2016;4(2):e94-e95. doi:10.1016/S2214-109X(15)00269-7
  76. Harper I. National tuberculosis control programmes of Nepal and India. Are they using the correct treatment regimens? J Health Stud. 2009;2:51-67.
  77. Barnhoorn F, Adriaanse H. In search of factors responsible for noncompliance among tuberculosis patients in Wardha District, India. Soc Sci Med. 1992;34(3):291-306.
  78. Engel N. Innovation dynamics in Tuberculosis control in India: the shift to new partnerships (Working paper series). The Netherlands: United Nations University - Maastricht Economic and social Research and training centre on Innovation and Technology ; 2009.
  79. Volmink J, Garner P. Directly observed therapy for treating tuberculosis. Cochrane Database Syst Rev. 2007;(4):Cd003343. doi:10.1002/14651858.CD003343.pub3
  80. Prakasha SR, Suresh G, D’sa IP, Shetty SS, Kumar SG. Mapping the Pattern and Trends of Extrapulmonary Tuberculosis. J Glob Infect Dis. 2013;5(2):54-59. doi:10.4103/0974-777X.112277
  81. Dholakia Y, Quazi Z, Mistry N. Drug-resistant tuberculosis: study of clinical practices of chest physicians, Maharashtra, India. Lung India. 2012;29(1):30-34. doi:10.4103/0970-2113.92359
  82. Hurtig AK, Porter JD, Ogden JA. Tuberculosis control and directly observed therapy from the public health/human rights perspective. Int J Tuberc Lung Dis. 1999;3(7):553-560.
  83. Porter J, Kielmann K. TB Control in India: the need for research in policy and decision making. Journal of the Indian Society of Health Administrators. 2003;1(XV):143-148.
  84. Hopewell PC, Fair EL, Uplekar M. Updating the International standards for tuberculosis care. Entering the era of molecular diagnostics. Ann Am Thorac Soc. 2014;11(3):277-285. doi:10.1513/AnnalsATS.201401-004AR
  85. Achanta S, Jaju J, Kumar AM, et al. Tuberculosis management practices by private practitioners in Andhra Pradesh, India. PLoS One. 2013;8(8):e71119. doi:10.1371/journal.pone.0071119
  86. Khan MS, Salve S, Porter JD. Engaging for-profit providers in TB control: lessons learnt from initiatives in South Asia. Health Policy Plan. 2015;30(10):1289-1295. doi:10.1093/heapol/czu137
  87. Baru RV, Nundy M. Blurring of boundaries: public-private partnerships in health services in India. Econ Polit Wkly. 2008;43:62-71.
  88. Ogden J, Walt G, Lush L. The politics of 'branding' in policy transfer: the case of DOTS for tuberculosis control. Soc Sci Med. 2003;57(1):179-188.
  89. De Costa A, Johansson E, Diwan VK. Barriers of mistrust: public and private health sectors' perceptions of each other in Madhya Pradesh, India. Qual Health Res. 2008;18(6):756-766.
  90. Ministry of Health and Family Welfare (MOHFW). Notification of TB Cases, Z-28015/2/2012-TB. New Delhi: MOHFW; 2012.