By Petra Stankard, Senior Technical Advisor HIV & TB, PSI, and Dr. Shekhar Waikar, Director of Programs, PSI-India
World TB Day, commemorated on March 24th each year, raises our awareness that despite effective drugs and diagnostics, tuberculosis remains a leading cause of death in much of the world. TB is second only to HIV as a killer infectious disease, with more than 10 million new infections in 2015 and an estimated 1.8 million deaths mostly in low- and middle-income countries.
In many countries, the private sector represents a major and growing source of services for suspected and active cases of TB. This often presents a challenge for national health systems that are ill-equipped to ensure that private providers provide safe and effective care.
In India, which is home to more people ill with tuberculosis and multi-drug resistant TB (MDR-TB) than any other country, PSI is playing a vital role in addressing this challenge. With support from the Global Fund, PSI-India’s Project Axshya is improving case detection and management of drug susceptible TB through the private sector, where studies show most people first seek care. The project works with private providers in three important ways.
Engaging with Mid-Level Providers
Across India, mid-level providers (i.e., registered medical practitioners; rural health care providers; ayurveda, yoga, unani, siddha and homeopathy practitioners; etc.) are often the first point of contact for individuals with persistent cough. Since the launch of the project in 2010, PSI-India has trained these providers to screen for TB and refer potential cases to appropriate TB clinics. As a result of this engagement, more than 25,724 suspected cases have been identified and 3,286 cases diagnosed and placed on treatment. This work also taught us how to engage with informal providers without threatening their business. Through regular one-to-one contact, PSI-India is able to reiterate the benefits of partnership, including improved reputation in the community and stronger patient relationships, motivating providers to support TB control efforts.
Building Capacity of Qualified Private Healthcare Providers
To date, PSI-India has sensitized 1,236 qualified private healthcare providers across nine cities, training them on the Standards of TB Care in India (STCI) in order to encourage proper diagnosis and treatment. The secret to the program’s success is the use of physician champions: private doctors who have successfully integrated the STCI in their own practices. These champions work with other private providers to resolve differences between the STCI and more common practices in the private sector, such as prescription of non-standard treatment regimens. While the STCI recommends four standard TB drugs, studies show more than 100 different drug combinations in use in the private sector. Champions can also address fears about engaging with the national TB control program, including concerns about losing patients to the public sector, increased reporting burdens and the belief that their effort would be without benefit to their business. The doctors employed by PSI are able to speak directly to these concerns from their own perspective and develop clear plans for how the program could support private providers in a manner that benefits both TB control and their bottom line.
Leveraging Information Technology to Bridge the Gap
Finally, PSI-India has successfully balanced TB control and incentivizing providers through the use of information and communication technology. PSI-India linked the government’s electronic TB notification system, Nikshay, with a platform that sends SMS and automated phone calls to patients to encourage treatment adherence and identify those that require follow-up counseling. This allows private providers to report confirmed cases to the national TB control program, while also extending their relationship with patients, without requiring additional resources – a measurable benefit to their practices. Since activities began, notifications of TB cases to the government have increased by 40-50% across all nine focus cities with more than 8,500 active cases notified to the national TB control program.
Improving case detection and treatment of tuberculosis is critical not only to the health of those infected, but also to preventing another problem: drug resistance. Because so many people infected with TB are getting inadequate treatment, resistance to first-line regimens is growing, posing a major threat to our ability to control the epidemic. While some may blame the private sector for contributing to this dilemma through failing to follow standards of care, PSI believes that these providers – both qualified and not – can be powerful allies in preventing drug resistance. In 2017, monitoring data from Project Axshya’s early implementation will help us understand if our work is having an impact. These findings will provide important information to the Indian government, as it continues its efforts to address this epidemic and ensure effective TB care to all who are infected.