DR-TB HIV Coordinator: Overview of Private Sector Engagement

Private sector engagement is a cross-cutting area under the BUILD pillar.

With an estimated 70% of tuberculosis (TB) patients seeking care in the private sector, the private sector involvement is important to ensure TB patients in private setting receive:

• Timely diagnosis
• Good quality treatment
• Protection from high out-of-pocket expenditure
• Other public health services such as:
  • Comorbidity testing
  • Contact investigation
  • Counselling
  • Adherence monitoring
  • Nutritional support 
  • Outcome reporting

Table 1 highlights the successful activities and planned activities to achieve private sector engagement under the NSP 2020-2025.

Resources

• National Strategic Plan for Tuberculosis Elimination 2020–2025

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Programmatic Management of Drug-resistant TB (PMDT) services for patients seeking care in the private/ other sectors can be accessed from the National TB Elimination Programme (NTEP) at all levels of the health system. 

• This includes care offered from the field level, through the network of Health and Wellness Centres (HWCs) under Ayushman Bharat, to tertiary care available in medical colleges/ nodal DR-TB centres and national-level institutions.

• It would be the responsibility of NTEP to reach out to all private providers of the respective area and make them aware of the free-of-cost services including drugs, diagnostics, and patient support available through the public sector.

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• The decision to avail these services depends on the willingness of the patient as well as the provider, nevertheless, the availability of these services should always be explained to the private providers. 

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• Similarly, patients should be made aware of free services through private providers and communities.

​Resources

• Guidelines for Programmatic Management of Drug-resistant TB in India, 2021.

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To increase support for Tuberculosis (TB) patients coming from the private sector, the National TB Elimination Programme (NTEP) has affirmed that public health response to all TB patients notified from the private sector will be the responsibility of the public health system. ​

Patients support services like adherence support, drug susceptibility testing, comorbidity detection, recording treatment outcomes, and infection prevention measures are already being extended to patients in the private sector. ​

Benefits given to TB patients in the public sector have also been extended to patients in the private sector including social welfare support.

As per the National Strategic Plan (NSP) 2017-25, support to patients from the private sector has already increased as follows:

• Nikshay Poshan Yojana (NPY): A nutritional support of 500 INR per month for the entire duration of treatment will be extended to all TB patients irrespective of the sector from which they seek treatment.
• Nikshay Sampark: A National Call Centre will serve as a platform for grievance redressal, notification of TB patients, and for treatment adherence support. This can be particularly useful in the case of private sector notification.
• Expanding the Patient-Provider Support Agency (PPSA) to 45 cities: This scheme comes with several supports for the private sector patients.
  • Free diagnosis with public sector Cartridge Based Nucleic Acid Amplification Test (CBNAAT)
  • Augmenting private sector notification, bringing them under the ambit of the support scheme
  • Free treatment with voucher mechanisms at the chemist shop
  • Direct Benefit Transfer (DBT) of NPY.
• Incentives to private providers/ chemists for notification and reporting treatment outcomes: As per NTEP’s recent policy 500 INR would be given at the time of TB notification and another 500 INR at the time of reporting the treatment outcome.

Increasing the reach to private providers and supporting patients under care in the private health sector has been the priority agenda of NTEP under Universal Access to TB Care. There has been much scope for innovations in this area.

Future Priority Areas to Explore 

• Extending PPSA initiative to other cities
• Establishing linkage to co-infection management in the private sector
• Establishing linkage to Drug-resistant TB (DR-TB) management in the private sector
• Expanding the scope of standards for TB care in India to be adopted by all practitioners in India (with a formal mechanism to review)
• TB drug sales surveillance to track all the un-notified TB cases

Resources

• National Strategic Plan for Tuberculosis Elimination, 2017–2025.

Kindly provide your valuable feedback on the page to the link provided HERE
 

Partnership options refer to the different modalities utilised by stakeholders of the National TB Elimination Programme (NTEP) to engage with a private-sector partner to improve the availability and quality of service delivery for TB patients.

The table below shows the partnership options that are currently available. The programme manager, based on the findings of the needs assessment, can identify the relevant partnership options that they can implement in their region.

Table: Available Partnership Options and their Scope of Services

The partnership options stated above are those which are currently identified and recommended in the NTEP Guidance Document on Partnerships.

A programme manager can innovate new partnership options which suit the local context, e.g., hiring a service provider for airborne infection control, facility-risk assessment, rehabilitation of DR-TB patients, or alcohol de-addiction programmes for people with TB, etc.

In scenarios where multiple systemic gaps have been identified during the needs assessment, the programme manager may consider using more than one partnership option, via bundling. Bundling refers to combining a series of partnership options in a logical and sequential manner to ensure that no patient is left out at any point in the care cascade.

Resources

• Guidance Document on Partnerships, RNTCP, 2019.

Assessment

As a public health responsibility to prevent transmission of TB infection and development of drug resistance it is essential to engage both the public and private sectors for effective TB prevention and control. A total of seven standards related to Public Health Actions (PHA) (Standard 12 to Standard 18) have been mentioned in the Standards for TB Care in India (STCI)-2014.  All patients notified from the private sector also need to be offered all public health actions. 

This could be achieved in collaboration with the local public health services and/or other agencies.  

1) Provide Access to Correct and Complete Diagnosis for Private Sector Patients

• In this regard all private providers must be sensitized, and their capacities must be built with respect to early diagnosis, prompt referral for sputum smear examination to the National TB Elimination Programme (NTEP) diagnostic facilities / NTEP accredited private labs.
• All private providers and chemists/pharmacists must mandatorily notify the TB patients to the local health authorities – District Health Officer / District TB Officer.

2) Provide Support for Treatment Adherence 

• A treatment support plan must be developed at the time of treatment initiation for all patients in the private sector too, in mutual consultation with patient and private provider.
• All patients receiving treatment from the private sector must also be eligible to receive counselling services and upon consent, home visit counselling sessions (or at the location convenient to the patient) may be provided to patients and their caregivers under the NTEP’s Public Private Mix (PPM) or in association with partner agencies providing counselling services under NTEP.
• Any instance of treatment interruption must be reported at the earliest through Ni-Kshay.
• The patients may also be linked to Ni-Kshay call-centers for adherence support. 
• The NTEP has also partnered with Patient Provider Support Agency (PPSA) / Patient Provider Interface Agency (PPIA) wherein vouchers were provided to private sector TB patients for utilizing subsidized TB diagnostic and follow up investigation services and can be scale up in high burden districts across the country with support from state governments/ Corporate Social Responsibilities (CSR) agencies.

4) Contact Tracing and TB Preventive Treatment

• All private providers must hold a responsibility to ensure that persons in close contact with patients who have infectious tuberculosis are evaluated at the earliest and managed in line with NTEP recommendations. The district health officers and district TB officers must be responsible to ensure this is being done on a regular basis.
• Eligible contacts should also be counselled for initiation of TB preventive treatment.

5) Linkage to Social Welfare and Protection

• Upon notification by the private provider and initiation of appropriate TB treatment, all patients seeking treatment under the private sector become eligible to receive direct benefit transfer (DBT) under the government of India's Nikshay Poshan Yojana (NPY)
• In districts where PPSA is available, PPSA staff may perform the linkage of private sector patients to DBT services and in districts where PPSAs are not available, the TB Health Visitor/ Senior Treatment Supervisor (STS) needs to undertake the public health action under the supervision of the PPM Coordinator.
• The patients may also be guided and linked to various other social protection and welfare schemes available under central and state governments. The partner agencies with expertise in referral linkages shall help the NTEP in achieving this.

6) Liaison with Professional Bodies

• Professional bodies such as Indian Medical Association and Indian Pharmaceutical Association must be involved for advocacy regarding the services available under public health actions of NTEP for the private patients.
  

Resources

• Guidelines on Programmatic Management of Drug-resistant TB (PMDT) in India, CTD, MoHFW, GoI, 2021.
• Mandatory TB Notification Gazette for Private Practitioners, Chemists and Public Health Staff, RNTCP, 2018.
• Notification of TB Cases: Amendments, MoHFW, GoI, 2015.
• TB Notification Order, MoHFW, GoI, 2012.
• National Strategic Plan for Tuberculosis Elimination 2017-2025, RNTCP, CTD, MoHFW, 2017.
• Standards for TB Care in India, WHO, 2014.

Assessment