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The Case of Ujjain District, India

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The Case of Ujjain District, India INT J TUBERC LUNG DIS 12(11):1333–1335 SHORT COMMUNICATION © 2008 The Union PPM: ‘public-private’ or ‘private-public’ mix? The case of Ujjain District, India A. De Costa,*† T. Kazmi,* K. Lönnroth,‡ M. Uplekar,‡ V. K. Diwan*† * Ruxmaniben Deepchand Gardi Medical College, Ujjain, India; † Karolinska Institutet, Stockholm, Sweden; ‡ Tuberculosis Strategy and Health Systems, Stop TB Department, World Health Organization, Geneva, Switzerland SUMMARY The World Health Organization and the Revised National laborate, although the areas for collaboration varied be- TB Control Programme (RNTCP) in India have advo- tween urban and rural providers. General altruism and cated public-private mix as essential for tuberculosis (TB) an opportunity to collaborate with the government were control. We conducted a cross-sectional sample survey of the main motivations. None of the providers had ever private providers (with various qualifi cations) in Ujjain been contacted by the RNTCP. Enthusiasm in the private District, India, to study willingness and motivation to sector has not been effectively exploited by the RNTCP. collaborate. Most providers were aware of the RNTCP KEY WORDS: public-private; India; tuberculosis and had referred patients there. All were willing to col- THE WORLD HEALTH ORGANIZATION (WHO) be qualifi ed doctors or paramedics, i.e., licensed pro- has stressed the importance of a stewardship role1 for viders in Western allopathic or Indian systems, or un- the public sector to engage private health care provid- qualifi ed. Urban (n = 74) samples were drawn from ers in working towards the public health goal of tu- providers working in municipal wards of Ujjain City berculosis (TB) control.2 India has one of the largest, and rural samples (n = 68) from those practising in most pluralistic private health sectors in the world.3 60 villages that constitute the Palwa epidemiological Engaging the private health sector has been one of the fi eld laboratory of Ujjain Medical College. Multistage goals set down in India’s Revised National TB Con- sampling was used to randomly select from among pri- trol Programme (RNTCP). vate health care providers with out-patient solo clinics There are a number of contextual examples of in the study area. public-private mix (PPM) for TB control in India.4 In July 2006, a questionnaire in Hindi initially pi- However, given the large private health sector in India, loted outside the setting was administered by a trained public-private involvement has not expanded rapidly. surveyor to each private health care provider in their It is important to understand why this is so, among clinic. It covered aspects related to provider character- both private health care providers and the RNTCP. istics, management of individuals with chest symptoms, We performed a cross-sectional sample survey of pri- knowledge of and interface with the RNTCP, willing- vate health care providers in Ujjain District—with ness and motivation to collaborate and interest areas. various qualifi cations and practising different systems The Ujjain Medical College gave ethical approval of medicine—to study their willingness to collaborate for the study. with the district RNTCP. Motivation to collaborate (or not) was also studied. RESULTS Urban private health care providers (mean age 50 METHODOLOGY years) included 66 qualifi ed doctors (33% practising Ujjain District (population 1.7 million, 62% rural) is Indian systems) and three paramedics. Rural private one of the 48 districts in the state of Madhya Pradesh, health care providers (mean age 35.5 years) included India. Lists of all district private health care providers nine doctors (eight practitioners of Indian systems were obtained from a door-to-door provincial map- of medicine), 42 paramedics and 23 unqualifi ed ping (sampling frame) done in collaboration with the providers. While doctors in Indian systems predomi- health department.5 Private health care providers may nated in rural areas, most paramedics (97%) were jan Correspondence to: Ayesha De Costa, Division of International Health, Department of Public Health Sciences, Nobels Väg 9, Karolinska Institutet, SE 171 77, Stockholm, Sweden. Tel: (+46) 8 5348 3337. Fax: (+46) 311 590. e-mail: ayesha_de_ [email protected] Article submitted 20 February 2008. Final version accepted 25 April 2008. 1334 The International Journal of Tuberculosis and Lung Disease Table Awareness of the RNTCP, willingness to collaborate, collaboration areas and motivation among private providers in Ujjain District, India, by location and qualifi cation Allopathic Indian system Rural Urban physicians* physicians† Paramedics Unqualifi ed (n = 74) (n = 68) (n = 45) (n = 29) (n = 45) (n = 23) n (%) n (%) n (%) n (%) n (%) n (%) Knowledge of or association with the RNTCP Heard about the RNTCP 72 (97.3) 66 (97) 44 (97.8) 27 (93.1) 45 (100) 21 (91.3) Referred a patient to the RNTCP 69 (93.2) 61 (89.7) 40 (88.9) 26 (89.6) 43 (95.5) 21 (91.3) Supervision of treatment in the RNTCP Self-supervised 45 (60.8) 54 (79.4) 39 (86.7) 19 (65.5) 24 (53.1) 17 (73.9) Supervised by another 2 (0.27) 0 0 0 1 (2.2) 1 (4.3) Don’t know 27 (36.5) 12 (17.6) 5 (11.1) 9 (31) 20 (44.4) 5 (21.7) Ever contacted by a RNTCP offi cial 0 0 0 0 0 0 Willingness to assist in the RNTCP 74 (100) 68 (100) 45 (100) 29 (100) 45 (100) 23 (100) Areas of collaboration Referral for diagnosis only 72 (97.3) 68 (100) 45 (100) 28 (96.5) 45 (100) 22 (95.6) Record keeping 29 (39.2) 1 (1.5) 1 (2.2) 4 (13.8) 13 (28.9) 12 (52.2) Defaulter tracing 29 (39.2) 0 0 2 (6.9) 18 (40) 9 (39.1) Motives for collaboration For the good of society 72 (97.3) 67 (98.5) 44 (97.8) 29 (100) 43 (95.5) 23 (100) For the benefi t of the individual patient 43 (58.1) 45 (66.1) 27 (60) 19 (65.5) 25 (55.5) 14 (60.9) For the opportunity to work with the government 3 (4) 22 (32.2) 18 (40) 5 (17.2) 2 (4.4) 0 * Western or modern medicine. † Indian systems include Ayurveda, Unani and homeopathy (recognised university degrees are awarded to practitioners trained in these systems). RNTCP = Revised National TB Control Programme; TB = tuberculosis. swasth rakshaks (barefoot doctors),5 with 6 months faulters or keep records; 29 (39.2%) rural providers, of training in allopathy. However, 114 providers mostly paramedics and unqualifi ed, were willing to (80.2%) reported practising allopathy, 26 (18.3%) do either or both of these. practised across systems and two practised exclu- Most providers reported that they would collabo- sively Indian medicine. Ten urban doctors and two ru- rate for altruistic reasons, while urban qualifi ed doc- ral paramedics were women. Two private health care tors saw collaboration as an opportunity to work with providers chose not to respond. the government. Only two rural providers expressed On average, rural and urban providers saw respec- an expectation of some return from the RNTCP for tively one and two individuals with chest symptoms their collaboration. per month. Urban providers said they would use spu- tum tests (97%) and X-rays (98.5%) to diagnose these DISCUSSION cases, compared to respectively 12.1% and 10.8% among rural providers. While most rural providers A lack of confi dence between the public and private (including physicians in Indian medicine) would refer health sectors in Madhya Pradesh6 and elsewhere7 has persons with chest symptoms for further treatment, been documented. This notwithstanding, practitioners 27 (35.3%) urban providers (all allopathic physicians) in the private health sector sampled expressed will- would treat them fi rst, and refer them only if there ingness to collaborate and were already referring cli- was no response after an average of 26 days. All 142 ents to the RNTCP. The areas for collaboration varied providers said they would refer the patient to the pub- between rural and urban practitioners and by qualifi - lic sector. cation. Urban providers possibly perceived record Most private health care providers, regardless of keeping and default tracing as unrewarding and erod- location or qualifi cation, had heard of the RNTCP and ing practice time. Retaining infl uence over the patients’ had referred a patient there. Only two rural providers treatment and follow-up were deemed important to (one paramedic, one unqualifi ed) knew that treatment both groups. Motivation to collaborate varied, but in the programme was supervised (see Table). On en- there was little expectation in return for collabora- quiring whether any RNTCP personnel had ever con- tion. It is, however, surprising that the enthusiasm tacted any of the private health care providers, all 142 observed in the private health sector has not yet been stated that they had never been contacted. However, exploited by the public sector, particularly the RNTCP. all expressed willingness to collaborate. Referral (al- No private health care provider was ever contacted ready ongoing) was perceived as a method of collabo- by anyone from the programme. Other PPM projects ration. Providers of all qualifi cations were willing to in India4 report engagement of private health care refer patients to the RNTCP for diagnosis, but were providers largely through one-to-one visits by pro- keen to take responsibility for the treatment (i.e., im- gramme staff. However, given the density of solo plementing anti-tuberculosis treatment and follow- practitioners in India, it is diffi cult for the RNTCP, up). Urban practitioners were unwilling to trace de- integrated within health services at the sub-district Public-private mix in India 1335 level, to contact and follow up each individual private vate care providers to collaborate.
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