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Jiang W, Dong D, Febriani E, Adeyi O, Fuady A, Surendran S, Tang S, Mutasa RU. Policy gaps in addressing market failures and intervention misalignments in tuberculosis control: prospects for improvement in China, India, and Indonesia. THE LANCET REGIONAL HEALTH. WESTERN PACIFIC 2024; 46:101045. [PMID: 38827933 PMCID: PMC11143451 DOI: 10.1016/j.lanwpc.2024.101045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/20/2023] [Revised: 02/23/2024] [Accepted: 02/29/2024] [Indexed: 06/05/2024]
Abstract
India, Indonesia, and China are the top three countries with the highest tuberculosis (TB) burden. To achieve the end TB target, we analyzed policy gaps in addressing market failures as well as misalignments between National TB Programs (NTP) and health insurance policies in TB control in three countries. In India and Indonesia, we found insufficient incentives to engage private practitioners or to motivate them to improve service quality. In addition, ineffective supervision of practice and limited coverage of drugs or diagnostics was present in all three countries. The major policy misalignment identified in all three countries is that while treatment guidelines encourage outpatient treatment for drug-sensitive patients, the national health insurance scheme covers primarily inpatient services. We therefore advocate for better alignment of TB control programs and broader universal health coverage (UHC) programs to leverage additional resources from national health insurance programs to improve the effective coverage of TB care.
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Affiliation(s)
- Weixi Jiang
- School of Public Health, Fudan University, Xuhui District, Shanghai, China
| | - Di Dong
- Health, Nutrition and Population Global Practice, World Bank, Washington, DC 20433, USA
| | - Esty Febriani
- Lecturer of Public Health Magister Heath Institute, STIKKU, West Java, Indonesia
| | | | - Ahmad Fuady
- Department of Community Medicine, Faculty of Medicine, Universitas Indonesia, Jakarta, Indonesia
| | - Sapna Surendran
- Health, Nutrition and Population Global Practice, World Bank, Washington, DC 20433, USA
| | - Shenglan Tang
- Duke Global Health Institute, Duke University, Durham, NC, USA
| | - Ronald Upenyu Mutasa
- Health, Nutrition and Population Global Practice, World Bank, Washington, DC 20433, USA
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Ricks S, Singh A, Sodhi R, Pal A, Arinaminpathy N. Operational priorities for engaging with India's private healthcare sector for the control of tuberculosis: a modelling study. BMJ Open 2024; 14:e069304. [PMID: 38508628 PMCID: PMC10952976 DOI: 10.1136/bmjopen-2022-069304] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2022] [Accepted: 01/16/2024] [Indexed: 03/22/2024] Open
Abstract
OBJECTIVES To estimate the potential impact of expanding services offered by the Joint Effort for Elimination of Tuberculosis (JEET), the largest private sector engagement initiative for tuberculosis (TB) in India. DESIGN We developed a mathematical model of TB transmission dynamics, coupled with a cost model. SETTING Ahmedabad and New Delhi, two cities with contrasting levels of JEET coverage. PARTICIPANTS Estimated patients with TB in Ahmedabad and New Delhi. INTERVENTIONS We investigated the epidemiological impact of expanding three different public-private support agency (PPSA) services: provider recruitment, uptake of cartridge-based nucleic acid amplification tests and uptake of adherence support mechanisms (specifically government supplied fixed-dose combination drugs), all compared with a continuation of current TB services. RESULTS Our results suggest that in Delhi, increasing the use of adherence support mechanisms among private providers should be prioritised, having the lowest incremental cost-per-case-averted between 2020 and 2035 of US$170 000 (US$110 000-US$310 000). Likewise in Ahmedabad, increasing provider recruitment should be prioritised, having the lowest incremental cost-per-case averted of US$18 000 (US$12 000-US$29 000). CONCLUSION Results illustrate how intervention priorities may vary in different settings across India, depending on local conditions, and the existing degree of uptake of PPSA services. Modelling can be a useful tool for identifying these priorities for any given setting.
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Affiliation(s)
- Saskia Ricks
- Imperial College London School of Public Health, London, UK
| | - Ananya Singh
- Clinton Health Access Initiative, New Delhi, India
| | | | - Arnab Pal
- Clinton Health Access Initiative, New Delhi, India
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Svadzian A, Daniels B, Sulis G, Das J, Daftary A, Kwan A, Das V, Das R, Pai M. Do private providers initiate anti-tuberculosis therapy on the basis of chest radiographs? A standardised patient study in urban India. THE LANCET REGIONAL HEALTH. SOUTHEAST ASIA 2023; 13:100152. [PMID: 37383564 PMCID: PMC10306035 DOI: 10.1016/j.lansea.2023.100152] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/30/2022] [Revised: 01/08/2023] [Accepted: 01/11/2023] [Indexed: 06/30/2023]
Abstract
Background The initiation of anti-tuberculosis treatment (ATT) based on results of WHO-approved microbiological diagnostics is an important marker of quality tuberculosis (TB) care. Evidence suggests that other diagnostic processes leading to treatment initiation may be preferred in high TB incidence settings. This study examines whether private providers start anti-TB therapy on the basis of chest radiography (CXR) and clinical examinations. Methods This study uses the standardized patient (SP) methodology to generate accurate and unbiased estimates of private sector, primary care provider practice when a patient presents a standardized TB case scenario with an abnormal CXR. Using multivariate log-binomial and linear regressions with standard errors clustered at the provider level, we analyzed 795 SP visits conducted over three data collection waves from 2014 to 2020 in two Indian cities. Data were inverse-probability-weighted based on the study sampling strategy, resulting in city-wave-representative results. Findings Amongst SPs who presented to a provider with an abnormal CXR, 25% (95% CI: 21-28%) visits resulted in ideal management, defined as the provider prescribing a microbiological test and not offering a concurrent prescription for a corticosteroid or antibiotic (including anti-TB medications). In contrast, 23% (95% CI: 19-26%) of 795 visits were prescribed anti-TB medications. Of 795 visits, 13% (95% CI: 10-16%) resulted in anti-TB treatment prescriptions/dispensation and an order for confirmatory microbiological testing. Interpretation One in five SPs presenting with abnormal CXR were prescribed ATT by private providers. This study contributes novel insights to empiric treatment prevalence based on CXR abnormality. Further work is needed to understand how providers make trade-offs between existing diagnostic practices, new technologies, profits, clinical outcomes, and the market dynamics with laboratories. Funding This study was funded by the Bill & Melinda Gates Foundation (grant OPP1091843), and the Knowledge for Change Program at The World Bank.
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Affiliation(s)
- Anita Svadzian
- Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, QC, Canada
- McGill International TB Centre, McGill University, Montreal, QC, Canada
| | - Benjamin Daniels
- McCourt School of Public Policy, Georgetown University, Washington, DC, USA
| | - Giorgia Sulis
- School of Epidemiology and Public Health, Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Jishnu Das
- McCourt School of Public Policy, Georgetown University, Washington, DC, USA
- Centre for Policy Research, New Delhi, India
| | - Amrita Daftary
- Dahdaleh Institute of Global Health Research, School of Global Health, York University, Toronto, ON, Canada
- Centre for the Aids Programme of Research in South Africa MRC-HIV-TB Pathogenesis and Treatment, Research Unit, Durban, South Africa
| | - Ada Kwan
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of California, San Francisco, CA, USA
| | - Veena Das
- Department of Anthropology, Johns Hopkins University, Baltimore, USA
| | - Ranendra Das
- Institute for Socio-Economic Research on Development and Democracy, Delhi, India
| | - Madhukar Pai
- Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, QC, Canada
- McGill International TB Centre, McGill University, Montreal, QC, Canada
- Manipal McGill Program for Infectious Diseases, Manipal Centre for Infectious Diseases, Manipal Academy of Higher Education, Manipal, Karnataka, India
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Yellappa V, Bindu H, Rao N, Narayanan D. Understanding dynamics of private tuberculosis pharmacy market: a qualitative inquiry from a South Indian district. BMJ Open 2022; 12:e052319. [PMID: 35074813 PMCID: PMC8788189 DOI: 10.1136/bmjopen-2021-052319] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
OBJECTIVES In India, retail private pharmacists (RPPs) are often patients' first point of contact for diseases, including tuberculosis (TB). We assessed the factors influencing RPPs' referral of patients with chest symptoms to the National TB Elimination Programme (NTEP) and the way business is carried out with reference to TB drugs. DESIGN We conducted semistructured interviews with a purposive sample of 41 RPPs in a South Indian district between May and October 2013. Data were collected from urban areas (21 RPPs) and rural areas (20 RPPs) employing the principle of data saturation. Data were analysed thematically using NVivo V.9. RESULTS Knowledge and compliance of RPPs regarding TB symptoms and regulatory requirements were found to be poor. The RPPs routinely dispensed medicines over the counter and less than half of the respondents had pharmacy qualifications. None of them had received TB-related training, yet half of them knew about TB symptoms. Practice of self-referrals was common particularly among economically poorer populations who preferred purchasing medicines over the counter based on RPPs' advice. Inability of patients with TB to purchase the full course of TB drugs was conspicuous. Rural RPPs were more likely to refer patients with TB symptoms to the NTEP compared with urban ones who mostly referred such clients to private practitioners (PPs). Reciprocal relationships between the RPPs, PPs, medical representatives and the prevalence of kickbacks influenced RPPs' drug-stocking patterns. PPs wielded power in this nexus, especially in urban areas. CONCLUSION India hopes to end TB by 2025. Our study findings will help the NTEP to design policy and interventions to engage RPPs in public health initiatives by taking cognisance of symbiotic relationships and power differentials that exist between PPs, RPPs and medical representatives. Concurrently, there should be a strong enforcement mechanism for existing regulatory norms regarding over-the-counter sales and record keeping.
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Affiliation(s)
- Vijayashree Yellappa
- Health Service Delivery, Institute of Public Health Bengaluru, Bangalore, Karnataka, India
- PPP Division, NITI Aayog, Delhi, Delhi, India
| | - Himabindu Bindu
- Health Service Delivery, Institute of Public Health Bengaluru, Bangalore, Karnataka, India
| | - Neethi Rao
- Health Service Delivery, Institute of Public Health Bengaluru, Bangalore, Karnataka, India
| | - Devadasan Narayanan
- Health Service Delivery, Institute of Public Health Bengaluru, Bangalore, Karnataka, India
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