Proposing a partnership
FIFTY per cent of all TB patients in India first contact the private practitioners. It is imperative, therefore, to involve the private sector of health into the Revised National Tuberculosis Programme (RNTCP). Advocacy for Control of Tuberculosis (ACT) is a project that in collaboration with the Tuberculosis Research Centre (TRC) and the Corporation of Chennai has developed a model to integrate private and public sector to control TB. Dr. NALINI KRISHNAN, Coordinator, ACT, discusses the ground realities with DR. UMA KRISHNASWAMY.
Dr. UMA KRISHNASWAMY (U.K.S.):
THERE is a growing realisation around the world that governments alone cannot control TB and that private-public partnerships are essential for supporting, expanding and sustaining national TB control programmes. It is surprising, therefore, that there are very few successful private-public partnerships in this area in India. What do you think is responsible for this?
Dr. NALINI KRISHNAN (N.K.): Although the need for private sector participation has been recognised while formulating the Revised National Tuberculosis Programme (RNTCP), as early as 1993, we have yet to see any real movement towards this end.
There are enough models in India to show that the concept can be made into a reality. However one surmises that it is obviously not a priority at this point in time for the RNTCP.
The Government has to take one of two paths: open up TB control in the private sector or ensure full utilisation of the RNTCP by all TB patients. The latter obviously cannot be done given the diversity and autonomy in healthcare and the right of the individual to shop around for the kind of care they prefer. The Government has before it the mammoth task of implementing, supervising and documenting its own programme to cover the whole country. The question is, is the RNTCP really committed to private-public partnerships in the sense of a true partnership? Or is it going to remain a soft area of the programme left to the initiative of a few groups? The concept has not percolated down to the level of the district tuberculosis officers who are supposed to identify possible partners. The various schemes for the private sector have not been widely publicised, so that there is very little awareness of the RNTCP and its initiatives towards partnerships.
There have been several discussions and workshops, following which it is mostly the private partner that has initiated programmes for TB control. For a true partnership to be established, the private sector health care has to be represented at the planning level and the modalities of involving the private sector have to be worked out jointly. On the other hand, what is happening now is that the Government presents a formulated scheme with a choice to participate or not, which does not evoke the interest of potential partners for whom public health issues may not be a priority at all.
For real partnerships to be formed, there must be a sense of ownership of the programme by the private healthcare sector.
The RNTCP is the most effective and viable option the country has today to reduce its TB burden. The programme needs aggressive marketing to the private sector healthcare, bringing it on board as a true partner.
Dr. U.K.S.: Collaboration is the fundamental principle for any successful partnership. Much more so in the context of involving private medical practitioners in the RNTCP to institute the DOTS strategy. Many private medical practitioners I have spoken to hesitate to involve themselves, because they perceive the functionaries of the RNTCP as donning a mantle of dictatorial control and not partnership. Is this true and to what extent?
Dr. N.K.: The RNTCP functionaries need to do some soul searching at this point of time, asking themselves if they are really convinced of the need for private sector involvement. What are the factors that the programme must consider? Even in areas covered by the RNTCP, patients will continue to seek private sector health care.
Therefore, private-public partnerships should be established to complement the Government's programme in a highly localised manner. But, private sector healthcare should be clearly defined. In India, this could range from private practitioners, to hospitals, nursing homes, polyclinics, alternative medical practitioners, quacks and pharmacists. Who are to be invited to join the partnership?
Can the Government consider keeping all TB services under its own management, making TB drugs unavailable through private pharmacies (where they are now available even without prescription) but only through Government centres and designated private practitioner partners? What can attract private practitioners to join this partnership? Does the private sector concern itself at all in public health issues? Is it not time for the Government to try to overcome the apathy in the private sector to give it a sense of involvement?
In our experience in Chennai and in the "Mahavir project" in Hyderabad and in several other projects in India, we have seen very enthusiastic response to the programme from private practitioners. The method of approach has obviously made a difference in these models.
The Government has to market the programme, inviting the private sector as equal partners. There has to be an attitudinal change in approaching, initiating and evolving methods for joint planning and implementation. The programme has to recognise the autonomous nature of private practice and formulate its approach accordingly, taking into account that there is no real incentive for the private practitioners except to appeal to their sense of community and social responsibility. The concept of private-public mix, in its true spirit, which is recognised by the top functionaries of the RNTCP, has to percolate down to programme managers and officers. In fact, I think that there has to be a specific training and orientation towards this within the RNTCP itself before inviting partnerships. One way to establish successful partnerships would be to have apex bodies at State or district levels with representation from the public and private sector to jointly identify partners, evolve by consensus methods for supervision and monitoring and make quality control a joint responsibility. Unless the partnership finds acceptability with both partners it will not be sustainable. Furthermore, we will not see the private sector really take on the burden unless it has a sense of ownership of the programme. In fact, we could look at a private sector partner as a franchisee who will implement the programme with conviction and feel responsible for the outcomes.
Dr. U.K.S.: The DOTS strategy relies on a standardised approach to the diagnosis, treatment and reporting of TB. Any deviations will lead to a disruption in programme monitoring, jeopardise quality control and ultimately harm the individual TB patient. However, many private practitioners have to rely on innovation when treating patients from the weaker socio-economic sections of society. How has the ACT sought to reconcile the divergent objectives of innovation and standardisation?
Dr. N.K.: The RNTCP and the DOTS strategy is one of the success stories in public health. The protocols have been based on years of research mostly from the Tuberculosis Research Centre in Chennai and have been validated by impressive results wherever the RNTCP is well implemented and in other countries the world over. Given this background, it should not be difficult for the private sector to abide by the same protocol.
In the Advocacy for Control of Tuberculosis (ACT) project, we look for private sector partners who believe in best practices and evidence based medicine. There is no scope for autonomy and innovation unless it is based on research or literature reviews. The private practitioner owes to his patient the benefits of research. Implementing the diagnostic, categorisation and treatment protocols set by the national programme is a major step towards standardising treatment and would in fact pave the way for higher quality of therapeutic interventions in other illnesses as well.
When private doctors are willing to accept and use drug information given to them by pharmaceutical companies, there should be no reason why they should question the treatment protocols prescribed by a public health programme, backed by field trials and research. Potentially, there is scope for innovation only in the methodology of DOTS, methods of easing the burden of the patient, advocacy and implementation and evaluation strategies for the partnership.
Dr. U.K.S.: Community participation is the key to tackling TB or indeed any public health issue. A unique feature of the ACT is that it depends on community participation via volunteer DOTS providers, who directly observe that the patient does indeed swallow the medicine. To what extent does the success of ACT depend on these men and women? Are they not the real key to the success of ACT?
Dr. N.K.: The ACT programme in Chennai has stood testimony to the strength that lies in the community when called upon to respond to a problem. The most truly rewarding experience we have had is the manner in which members of the public have come forward to assist us in the DOTS programme. These people come from different walks of life with different cultural and socio-economic backgrounds and are willing to serve as DOTS providers for our patients.
They have not expected any compensation at all and have volunteered their time supervising every dose of medicine given, supporting and encouraging the patient to complete treatment over a period of six months. When talking to them, one realises that these individuals have a true sense of community spirit. We have seen the same response in several industries, NGOs and senior citizens' groups which work with us.
These men and women are willing to take that extra effort to make treatment possible for patients with TB. This is a huge resource waiting to be tapped and the programme would be strengthened considerably if we recognise and take help from these people or groups who/which have such a strong sense of involvement and responsibility to the community.
Similarly, the private hospitals, which are now part of the ACT network have offered their premises and put their staff at the disposal of their DOTS programme as a contribution to the community. Addressing TB as a public health issue has evoked a very generous response from the community at large.
Dr. U.K.S.: With the ACT network enlarging every day, what are your future plans? Do you see this network encompassing the entire city of Chennai in the not too distant future, thus bringing the benefit of free TB treatment to every economically disadvantaged patient within this city?
Dr. N.K.: We are greatly encouraged by the response we have had from the private sector healthcare towards accepting and implementing the DOTS strategy. The ACT has had the unique distinction of having the support of the Tuberculosis Research Centre (TRC), Chennai, to set up and run this model. This has given us tremendous confidence as we are able to constantly review our work with the experts there and make mid-course corrections where required. The TRC is also assisting us in documentation and quality control.
The Resource group for Education and Advocacy for Community Health (REACH) is essentially an advocacy group and having demonstrated a fairly successful model, the ACT project, we intend to continue creating awareness and recruiting more participation in the RNTCP.
We are now working towards forming networks for each Chennai Corporation zone, enlisting private hospitals and laboratories to offer TB care services and ultimately linking them up with the private practitioners in that area and the Chennai Corporation Primary Health Centres. The corporation has been of tremendous help in this respect.
We are assisting private healthcare providers to enable them run DOTS centres on their own with support from the Corporation in terms of free drugs for patients and from ACT in terms of link ups with community DOTS providers and laboratories. We hope to utilise the strength of the private-public partnership network built for TB control in other areas like sexually transmitted infections, HIV control, breast disease awareness and other public health issues.
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Myths and facts
What is Tuberculosis?
TUBERCULOSIS (TB) is a chronic infectious disease caused by bacteria called Mycobacterium tuberculosis, which can affect any part of the body, often the lungs.
Who is at risk for TB?
Every one is at risk because India has the largest number of TB patients. Approximately 2.2 million cases of TB are detected and treated every year and 1000 Indians die every day of it. While prolonged direct contact increases the risk for all of us, babies, children, diabetics, HIV/AIDS, cancer or transplant patients, whose immunity is lower than normal are more at risk.
How does one get TB?
When a patient talks, coughs, sneezes or even sings, the bacteria is spread through the air. People nearby inhale the droplets and are infected. Such contact is usually within a family, school or work place. In most people (95 per cent of individuals) the body's defences are able to fight and stop bacterial growth. But in some cases, the bacteria settle in the lungs and begin to grow. From there, they may spread to the kidney, spine or brain through the blood stream.
What are the symptoms of TB?
They depend on which part of the body is affected. In the common problem of lung TB, there may be cough lasting longer than three weeks, low-grade fever particularly in the evenings, a lack of appetite and loss of weight.
How is TB diagnosed?
The doctor will listen to the lungs with a stethoscope for abnormal sounds created by the infection and then order a sputum test for TB on three consecutive samples. In government institutions, such as district tuberculosis centres and corporation dispensaries, this is done free of cost. Other tests that may be required are: x-rays, sputum cultures and Mantoux skin test.
How is TB treated?
A combination of drugs is used to fight TB. Hospitalisation is not necessary for most patients. One may be advised to stay at home to avoid infecting others for the first few weeks of treatment. After taking medicines for a few weeks, the patient is no longer infectious and hence will be permitted to return to normal routine. The medicines are safe when taken under a doctor's careful supervision. TB bacteria die very slowly and the minimum period of treatment is six (sometimes nine) months.
Though a person may feel better after a few weeks of treatment, it must be continued as per the doctor's instructions. Premature discontinuation of treatment leads to recurrence of the disease. The bacteria may also become resistant to the drugs and stronger drugs may be required.
How does one remember to take these drugs for so long?
Participation in the DOTs programme, recommended by the Directorate of Health Services of the Government of India and by the World Health Organisation, is the solution. The key factor in DOTs is that a DOTs provider (usually a health care worker or friend or a volunteer in the local community) will meet the patient thrice a week at the clinic, home, work spot, or any other convenient location. He or she will bring the medicines which are given free of cost (by the Government) and make the patient swallow the medicine.
Since the drugs are swallowed in his or her presence, it is called Directly Observed Treatment (DOTs). The letter `s' after DOT stands for "short course" of medication (six to nine months).
DOTs helps in several ways: The DOTs provider ensures that one takes the medicines; The DOTs provider will look out for side-effects and remind one to visit the doctor or nurse regularly while under treatment; Participation in DOTs has been proven to double the cure rates in India.
How should a TB patient prevent infection from spreading to others?
Medicines must be taken regularly and the course completed. Sputum tests must be undertaken periodically. They show whether the drugs are effective and whether one is infectious or not. The mouth must be covered when coughing, sneezing or even laughing. The cloth must be washed separately and dried in sunlight before reuse. Paper tissues should be put into a closed paper bag and disposed.
One must not go to work till the doctor gives permission. Close contact, particularly with children, is best avoided. The patient's room must be well ventilated and aired often. People cannot get infected with TB through handshakes or by sharing the same toilets.
Is TB curable?
Yes, TB is curable, if treated scientifically. Having TB is not a stigma and does not stop one from leading a normal life.
Dr. UMA KRISHNASWAMY
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