By Nina Hasen, Vice President, HIV and Tuberculosis, PSI
Imagine you have a cough that just won’t go away.
First, you visit your local pharmacy and pick up your usual remedies. Nothing helps, so you visit your general practitioner (GP). They try several medications and tests before finally realizing—or not—that you actually have a life-threatening tuberculosis (TB) infection. In India, over half the people being treated for TB at any given moment are doing so in the private sector. For many, the journey to accurate diagnosis and effective treatment takes months.
PSI India is leveraging the power of existing ePharmacy companies to shorten this journey by connecting private providers with public labs; facilitating doorstep delivery of free TB drugs; and offering treatment adherence support—to bring high-quality TB care to the consumer in one, seamless system.
The TB Challenge in India
India has the largest number of TB cases in the world. In 2016, 1 in 475 people in India contracted TB, and 435,000 people died from the disease. Meanwhile, there are more than 850,000 cases of TB each year in India that are either undetected and untreated—or diagnosed and treated by private healthcare providers who may not report them to the National TB Program (USAID).
In fact, in India, over half of TB patients seek care from private providers. These private providers make their living through consultation fees, and by selling drugs to address ailments. These incentives don’t always align to deliver the most efficient and effective TB care, meaning that many of these patients may suffer from the disease longer, have worse health outcomes, and infect others around them.
Seizing the ePharmacy Moment
PSI India works to improve both private and public sector TB care since 2016. While the quality of care has improved, several key barriers persist. Private providers don’t reliably test their patients for TB using the best diagnostics and they don’t reliably put their TB-positive patients on the best drug regimens. Several years ago, as the internet and smart phones began to reshape healthcare, the team saw an opening to address these chronic challenges. In partnership with the state of Madhya Pradesh, they began crafting a system that could leverage the best of a burgeoning new digital marketplace to tackle the ancient scourge of TB.
“ePharmacies” are online systems that link prescribers and patients to drugs, allowing patients to place drug orders online with ePharmacies, who then deliver those medications directly to the doorsteps of patients. With funding from the SHOPS Plus project through USAID, PSI India adapted the ePharmacy model to address the needs of private providers and patients with TB. Working with key stakeholders such as ePharmacy player MedLife, the Central TB Division and the Madhya Pradesh State TB Elimination Program, PSI India launched a project to bring the benefits of ePharmacies to the TB response.
The goals of the project were simple albeit not easy. The system had to:
- Encourage providers to order the right test for a patient who presents with TB symptoms
- Ensure those tested TB positive get registered in the National TB patients tracking system
- Enable patients who test positive for TB to get the appropriate drugs free of charge
PSI worked with Medlife to customize their system, making it easy for private GPs and their patients to sign up and for GPs to order TB tests through the system. More importantly, they worked with Medlife to ensure that TB tests were routed to public labs that would test these private patient samples using the same “gold standard” diagnostic tools used in the public health system. Medlife and PSI also built an interface to ensure that positive results would be registered with the National TB System, and that results would be routed back directly to the provider and patient. At that point, Medlife’s powerful ePharmacy system would kick in, delivering the free TB drugs directly to the patient.
Over the course of 13 months, PSI and Medlife piloted this intervention in three markets. A total of 2,500 TB patients enrolled in Medlife’s online platform to receive free TB drugs; overall, 7,000 orders have been processed so far and 98 percent of them delivered on time to their respective customers. The ePharmacy model was also extended to patients being treated for TB in the public sector during the COVID-19 pandemic. This ensured an uninterrupted supply of TB drugs to these patients while reducing their exposure to COVID-19. The program was so successful that Madhya Pradesh State has allocated budget to continue it without further donor funding.
Something for everyone
The beauty of this system is that it adds value for every actor in the market:
- Madhya Pradesh State gets great TB care for their citizens using the private sector – for just a bit more than the state would pay for public sector care – basically the cost of ePharmacy deliveries. Improved TB care means less onward transmission and, over time, a lower overall burden of TB.
- Private providers get a small payment each time one of their patients tests positive, incentivizing them to actively screen for TB. Furthermore, because these patients return to the provider regularly over the course of TB treatment, providers gain a reliable revenue stream and higher patient engagement.
- Patients are the big winners. They get rapid, accurate diagnoses of their cough and high-quality treatment delivered to their doorsteps at no cost. Most importantly, they get many more years of healthy life.
ePharmacy and COVID-19
While PSI India didn’t plan this intervention with a global pandemic in mind, the timing could not have been more critical. At the moment when access to clinics and labs became constrained in India, the ePharmacy model was taking off, allowing the private sector to continue diagnosing and treating TB patients. Pulmonary TB is a devastating disease of the lungs, and ensuring that those infected can protect themselves from COVID-19 is essential. Going forward, ePharmacy models offer tremendous promise, not just for reducing the global burden of TB, but for improving the quality of care across many diseases and conditions.
ePharmacy combined with other digital health elements could:
- Incorporate tele-health appointments that further protect providers and patients and expand access to more remote areas
- Deliver the data to support a Ministry of Health digital dashboard that showcases increasingly accurate TB case information nationwide, thus allowing for proactive, targeted allocation of resources across both public and private health sectors
- Be adapted to address the ongoing treatment needs for other major diseases, such as HIV, diabetes, and hypertension
- Be translated to other countries and regions, taking into account the prevalence of public-private health partnerships, ePharmacy options, and digital penetration
This ePharmacy model is just one example of how PSI is helping governments reach the Sustainable Development Goal of healthy lives and well-being for all, through leveraging digital tools and optimizing mixed public and private health systems.