Evaluation of the Results Based Financing Strategies for Tuberculosis Care in India

Project Summary
Recognizing the critical need to engage with Private Practitioners (PPs), the Government of India (GoI) introduced Public-Private Mix (PPM) schemes to involve them in the Revised National TB control Program (RNTCP). Studies have identified a number of barriers for effective collaborations between RNTCP and PPs. Additional research was required to understand the dynamics of the private TB market and PPs’ motivations and disincentives to participate in PPM schemes., This study was conducted in two locations in Karnataka state, namely Tumkur district (rural) and KG Halli (urban slum) in Bangalore. Mixed method study design was used. It involved primary and secondary data collection, thematic analysis of qualitative data collected through interviews with PPs, RNTCP staff, technocrats (providing technical assistance to GoI), TB patients who have completed private TB treatment, private diagnostic laboratory technicians, and private pharmacies.

It was found that there was a lack of trust and mutual understanding between the public and private providers. PPs raised concerns about the poor functioning of RNTCP, such as long turnaround time for sputum examination, problems with DOTS delivery, technical incompetence of medical staff in government primary health centers (PHCs) to deal with drug toxicity, bureaucratic hurdles in disbursement of incentives, etc. One important problem was that RNTCP treated all private health providers equally, ignoring the vast diversity of the private health sector. The straitjacket approach of RNTCP was also pointed out by RNTCP officials as a barrier for collaboration. The fundamental problems were the non-alignment of motivations, ideologies, and mode of functioning of the public and private sectors.

Expenditure analysis for TB care showed that a TB patient spends up to INR 21,000.00 (~USD 350) on direct health care cost. A small chunk of this expenditure went towards doctors’ consultation fees. PPs have a significant financial incentive to retain TB patients since they also receive kickbacks from diagnostic laboratories and pharmacies (~30%), in addition to consultation fees. Thus, PPs can earn up to INR 8000 (~USD 140) from treating a single TB patient. This makes any financial incentive offered by the government under PPM schemes seem insignificant to PPs, especially when coupled with the bureaucratic hassles of obtaining that amount. Kickbacks seem to be entrenched in the private health care setup with some large establishments even maintaining systematic ledgers for this purpose. It was observed that kickbacks became less common in areas where the public sector health facilities were reputed. Thus, the bargaining power of PPs is inversely proportional to the strength of the public health system in an area. Assessment of the regulatory environment to engage with PPs demonstrated that PPs were largely aware about TB notification, but less aware of the exact mechanism and procedures.

Introduction
World health assembly declared Tuberculosis (TB) as a ‘Global emergency’ and adopted Directly Observed Treatment Short course (DOTS) strategy for control of TB in 1993. In India, TB remains a major global health problem, accounting for 26 per cent of all TB cases worldwide, with an estimated annual incidence of 176 cases per 100,000 persons in 2012. Over the years the private health sector in India has grown markedly. Most patients with respiratory symptoms first consult Private Sector health Providers (PSPs). Recognising the critical need to engage with Private Practitioners (PPs), the Government of India (GoI) introduced Public Private Mix (PPM) schemes to involve them in the Revised National TB control programme (RNTCP). Studies have identified a number of barriers for effective collaborations between RNTCP and PPs. Additional research was required to understand the dynamics of the private TB market and PPs’ motivations and disincentives to participate in PPM schemes.

Objectives
The goal of this research was to understand the private TB market dynamics and the motivations and disincentives for private practitioners (PP) to participate in Public Private Mix (PPM) schemes of the National TB control programme (RNTCP).

Specific objectives of this study are:
1. To examine the level and extent of involvement of PPs in the PPM-TB schemes.
2. To analyze PP’s contribution to RNTCP in terms of case detection and treatment outcomes.
3. To chart the perceptions of different stakeholder (PPs, Govt. officials implementing RNTCP, field staff of RNTCP and technocrats) about collaborating with RNTCP and their preferred modes of collaboration vis-à-vis RNTCP programme managers’ expectations.
4. To understand the incentive structure and functioning of the private market for the TB services.

Methodology
This study was conducted in Tumkur district (rural) and KG halli (urban slum) in Bangalore, Karnataka. We used mixed methods study design. It involved primary and secondary data collection, thematic analysis of qualitative data collected through interviews with private practitioners (PPs), RNTCP staff, technocrats (providing technical assistance to GoI), TB patients who have completed private TB treatment, private diagnostic lab technicians and private pharmacies. This study was conducted in Tumkur district (rural) and KG halli (urban slum) in Bangalore, Karnataka. We used mixed methods study design. It involved primary and secondary data collection, thematic analysis of qualitative data collected through interviews with private practitioners (PPs), RNTCP staff, technocrats (providing technical assistance to GoI), TB patients who have completed private TB treatment, private diagnostic lab technicians and private pharmacies.

Location of study sites:

wb-tbmap

1. Vijayashree Yellappa, HimaBindu, Devadasan Narayanan. T. Battaglioli, P. Van der Stuyft. Understanding Retail Private Pharmacist’s Role in Private Tuberculosis Market: A Qualitative Inquiry from a South Indian district. 2017 (Submitted to TMIH).

 

  1. Vijayashree Yellappa, Neethi Rao, N.Devadasan. Incentives for tuberculosis care in the private sector in India: a qualitative studyWorld Lung Health Conference, Barcelona, Spain, 2014.
  2. Vijayashree Yellappa, Neethi Rao, Hima Bindu, N.Devadasan . Retail Private Pharmacist’s knowledge and perceptions to collaborate with National Tuberculosis Programme: Qualitative Study, South India. World Lung Health Conference, Cape Town, South Africa, 2015.

Project Report submitted to World Bank on 31.12.2013, Contract No. 7165612.
Vijayashree Yellappa,Devadasan N, Neethi V. Rao, Amruthavalli, B. L Himabindu, C M Munegowda, Ramaiah N. Evaluation of Results Based Financing Strategies for Tuberculosis care and Control in India. 2013.

Duration of project

January 2013

to 

December 2013


Funders

World Bank (contract number: 7165612)


Admissions open for eSWaRM

Study Team

Vijayashree Yellappa

N Devadasan

Neethi V Rao

B. L.Himabindu

Munegowda C M

Ex-Staff(Institute of Public Health)

Amruthavalli

Ex-Staff(Institute of Public Health)

Ramaiah N

Ex-Staff(Institute of Public Health)