Direct Engagement

The private-sector health facilities have experts and infrastructure to manage TB cases. Under the direct engagement partnership model, the programme manager directly engages private-sector health facilities which provide TB services to ensure that standards of TB care reach all the patients in that facility.

In a region where there is no dedicated Patient Provider Support Agency (PPSA), the National TB Elimination Programme (NTEP) can directly empanel and engage a private/ corporate/ trust hospital and designate them as “TB Treatment Centres”.

Services that can be provided under this model are:

1. Identifying presumptive TB cases and testing them for TB with reimbursement of testing cost to the laboratory.
2. Notifying and managing drug-sensitive TB with reimbursement of medicine cost to the disbursing chemist.
3. Managing ambulatory treatment support of Drug-resistant TB (DR-TB) as per need.
4. Bundling treatment services with public health actions by engaging facilities which can do both directly or who can engage another service provider to ensure complete coverage of public health actions for patients treated in their facility.
5. Providing specialist consultation when the NTEP does not have enough specialist doctors to manage patients or requires additional specialist doctors.

Covering Private Sector TB Patients through Public Health System: The Mehsana Model of Universal Access to Free TB Care, Gujarat

• Mehsana is a town in Gujarat implementing India’s first pilot allowing for universal free anti-TB drugs in India.
• The programme is managed by the district TB office, supported by technical partners, and has engaged a large proportion of private providers.

Overview of the Mehsana Model

1. The patient goes to a Private Provider (PP)/ chemist/ pharmacist.
2. PPs/ chemists refer presumptive TB cases for chest X-rays or smear tests.
3. The patient is provided with a unique number (i.e., a voucher) when prescribed a diagnostic test. The e-voucher links the patient with NTEP.
4. A call centre operated by an NTEP staff member generates and tracks this e-voucher and reimburses the diagnostic facilities for the test.
5. If the initial test is positive, the provider refers the patient to a formal provider for Drug Susceptibility Testing (DST). Costs of these tests are also reimbursed via the e-voucher.
6. The PP also notifies the case, and incentives for notification are sent to the PP/ chemist.
7. Monthly prescriptions come with an e-voucher, which patients can use to obtain medications (from a list of approved anti-TB drugs) from any local chemist who participates in the initiative

Over the entire course of the treatment process, the TB programme in Mehsana deploys field workers to monitor and facilitate drug compliance via home visits.

All the chemists and doctors in Mehsana were mapped and engaged. Doctors were trained to help them tailor prescription practices. NTEP offered no financial incentive to the doctor and only offers a minor overhead charge to the pharmacists.

In the end, the programme provides a win-win situation for all: the chemist acts as a referral point, the patient gets the right diagnosis and free drugs, and the private physician retains his or her patients.

Key Results

Of all the patients who initiated anti-TB treatment through the initiative, 72% successfully completed their regimens.

Lessons Learned from the Mehsana Model

Mehsana helped demonstrate proof of concept for a model that directly engages private healthcare providers to diagnose, notify, and treat TB cases and to strengthen adherence to the TB treatment regimen.

• Since PPs are often the first point of contact for patients, it is important to directly engage them by offering the right incentives to promote standard TB care.
• Information, Communication and Technology (ICT) tools were used at various stages (during the mapping exercise and the use of e-vouchers) of the initiative. Thus, the role of technology in existing partnership options must not be discounted.

Resources

• NTEP Training Modules (5-9) for Programme Managers & Medical Officers, NTEP, 2020.
• Mainstreaming Private Healthcare Systems for Tuberculosis Control, The Bridgespan Group, 2018.
• Ending Tuberculosis in India: A Political Challenge & an Opportunity, IJMR, 2018.

Assessment