Tuberculosis elimination in India: What’s next for private-sector engagement?

March 23, 2022 by Shibu Vijayan

PATH has been spearheading tuberculosis elimination efforts in India since 2014, and successfully so. It is time to identify and address emerging priorities.

A PATH field officer interacts with the chemist at Dr. Vikas Oswal’s clinic. Dr. Oswal is part of the public-private linking initiative that has helped treat tuberculosis patients through the Patient Provider Support Agency model. Photo: PATH.

A PATH field officer interacts with the chemist at Dr. Vikas Oswal’s clinic. Dr. Oswal is part of the public-private linking initiative that has helped treat tuberculosis patients through the Patient Provider Support Agency model. Photo: PATH.

India carries one-fourth of the global burden of tuberculosis (TB). Among other efforts, the government of India has developed the National Strategic Plan 2017-2025, which outlines approaches to eliminate TB by 2025. Private-sector engagement is a key strategy in the plan.

PATH has been a leader in private-sector engagement efforts in India since 2014. What started as a modest pilot in three districts across two states was scaled up across the country as the Patient Provider Support Agency (PPSA), and implemented as part of Project JEET (Joint Effort for the Elimination of Tuberculosis). JEET has been institutionalized with domestic funding. PATH has played an integral part throughout this pilot to institutionalization journey.

PPSA, an evolved model of the modest pilot, now manages bundled services under private-sector engagement and augments the capacity of the government of India’s National Tuberculosis Elimination Program to monitor and manage the needs of private-sector TB patients. Under PPSA, a third-party agency is onboarded to engage private-sector doctors who treat patients with TB and provide end-to-end services, including diagnosis, notification, patient adherence and support, and treatment linkages. Today, PPSA is active in 203 districts across 23 states in India.

Five focus areas that need to be addressed

So far, PPSA has emerged successful in improving the provision of end-to-end TB services to patients who seek services in the private sector. However, in addition to scaling PPSA across the country, the implementation of the model has helped PATH identify priorities and focus areas that need to be addressed.

1. Capacity-building of partners

Observations from implementation show that there exists a gap in the capacity of third-party nongovernmental organization staff and district-level government functionaries across components of the model such as budgeting, documenting, and implementing the bidding process, among others. PATH is taking the lead to address the training gaps through several efforts, including conceptualizing a training plan, developing the training curriculum, providing hand-holding support, and scheduling virtual trainings.

2. Applying new technology

Technology remains at the core of all current and future public health efforts. As PPSA scales, efficient use of available and evolving technology is a focus for the program. One such area is exploring digitization of PPSA status and “smart payments” or e-RUPI for all partners to ensure on-time payments.

e-RUPI is a one-time, contactless, cashless electronic voucher–based digital payment system that uses SMS and quick response codes to facilitate transactions. This innovation has the potential to be scaled up and enable TB patients and partners to effectively utilize benefits provided by the national elimination program. This has become a priority, as delayed payments to partners (e.g., private-sector doctors, agencies, laboratories) have remained a challenge, and it is time to address it head-on to keep the momentum going. PATH is working with donors such as the Bill & Melinda Gates Foundation to explore testing of unique digital payment systems that can contribute to long-term success of the program.

3. Integrating mental health

Addressing mental health issues has become a mainstream conversation since the pandemic. Additionally, there is growing evidence to show that providing support in the form of counseling can improve treatment adherence for diseases such as TB. The current PPSA model focuses on end-to-end management of TB that begins from diagnosis and ends at treatment completion, with mental health as an ad-hoc component. But it is critical that psychosocial support becomes embedded in the program.

4. Raising the standards of care

PATH is working to ensure that all TB patients receive the highest standards of care and support from health care providers of their choice. The need for quality and standards in TB care is particularly acute in India, where a largely unregulated and unmonitored private sector accounts for almost half of the TB care delivered, and is hindered by challenges in the quality of diagnosis and treatment. PATH is working with partners to revise the Standards of TB Care in India, considering the changes in the program since 2014 when these standards were first drafted.

5. Advancing vaccines against TB

Effective, affordable, and equitable vaccines are the future of TB elimination. The lifesaving potential of vaccines has been further reinforced by the pandemic. Multiple trials of potential TB vaccines are underway, but current efforts in TB vaccine development are scattered across the globe and should be brought together for a quicker and efficient response. PATH is ready to share its expertise on vaccine development and rollout to take this mission forward.

PPSA is working but there’s more to do

Since implementation of PPSA, the TB notification rate increased from 72 percent in 2018 to 81 percent in 2020—realizing the Global Fund to Fight AIDS, Tuberculosis and Malaria’s commitment to achieve successful treatment outcomes for 70 percent of all notified patients. Further, the uptake of PPSA and universal drug susceptibility testing increased from 4 percent in 2018 to 52 percent in 2020. Though much work is left to be done, PPSA’s progress shows that we are moving in the right direction. Let’s continue addressing the identified priorities, creating more impact, and successfully making TB a challenge of the past.