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.
It is recommended that the RNTCP re-examine the mechanisms of collaborating with the PPs and become more flexible to accommodate the diverse private health sector. The current model of results-based financing needs a rethink to include creative nonfinancial measures and decentralized and non-bureaucratic administration of locally appropriate incentives. PPM activities should also be closely monitored with improved reporting systems. TB control regulations should be widely advertised and then strictly enforced.
