Background

Dr Vijayashree Yellappa started her PhD in December 2012. Her study focuses on understanding the modalities foroptimizing the involvement of private practitioners in the National Health Programmes in India, using National Tuberculosis Control as a tracer condition. She is registered at Ghent University, Ghent, Belgium. Her promoters include Prof.Patrick Van der Styuft who teaches at Department of Medicine, Ghent University; Prof. Bart Criel, co-promoter from Department of Public Health, Institute of Tropical Medicine, Antwerp Belgium and local promoter Dr. N Devadasan, Director, Institute of Public Health, Bangalore, India. She is expected to complete her PhD by late 2016.

Introduction

In India, the private health sector plays an important role in the provision of health care. Government of India has been involving the Private Sector Providers (PSPs) through Public Private Partnerships (PPPs) in realising public health goals through different partnership mechanisms such as contracting, franchising, social marketing, vouchers and social health insurance. Assessment of these PPPs have concluded that they are context specific, do not allow for easy generalisations and that in most of the cases, individual charismatic leadership seems to have played a critical role in achieving the success. Given this context, we proposed to study PPP in National Tuberculosis Control (NTP) in Tumkur District, situated in Karnataka, South India.

NTP draws special attention here, because of its long history of efforts to involve PSPs, which dates back to 1995. NTP has been making systematic efforts to involve PSPs through PPM (Public Private Mix)-DOTS (Directly Observed Short Treatment Short Course) strategy to effectively link NTP with PSPs, so as to detect Tuberculosis (TB) suspects timely and provide standardised treatment to TB patients. For this purpose, NTP has published PPM-DOTS guidelines in 2001-2002. Despite the promise shown by few PPM-DOTS models, uptake of PPM schemes by PSPs has been poor. Currently, the NTP claims that several thousands of Private Practitioners (PPs) are collaborating under various PPM schemes, but in 2014 only 13,150 formal allopathic PPs in the entire country were involved with NTP. The vision of the GoI is for a ‘TB free India’. But, given this state of affairs, we do not know much about the factors determining the performance of PPM-TB. Hence, we proposed to study ‘what’ determines the performance of PPM-DOTS in India and understand ‘how’ and ‘why’ certain PPM-DOTS work or fail. In this study, we particularly focused on for-profit, formally trained, private practitioners (PPs) practicing modern medicine.

Methodology

The study consisted of two phases. Phase one employed mixed methods design (2012-2013). As a first step, we assessed the participation of PPs in the NTP for the year 2011 using secondary data. Since, comprehensive register of PPs practicing in the area was not available, we mapped the PPs using GPS. Quantitative analysis showed, none of the PPs had formally signed-up for any PPM scheme and only 24% of them had referred any case to NTP in in 2011 (Article can be accessed here). As a second step, we conducted a qualitative study in the same area with stakeholders like PPs, TB patients and NTP staff at sub district, district, state and national level to explore the barriers for collaboration.

In the Phase two (2014-2015), we designed an intervention package based on the recommendations given by various stakeholders in phase one research. The activities where aimed at improving the collaboration between PPs and the NTP. We chose quasi-experiment design to evaluate the intervention as it is delivered in a real world setting by proportionate random allocation of PPs (100 in each group) practicing in the study area to an intervention (receiving a package of interventions to improve referral and notification) and a control group. As main outcomes, we assessed the proportion of PPs referring presumptive TB cases to the NTP and the proportion of PPs notifying TB cases on private treatment to the NTP, in the intervention versus control group at the end of the intervention. The duration of the intervention was 12 months starting from December 2014.