What would it cost to scale-up private sector engagement efforts for tuberculosis care? Evidence from three pilot programs in India

Abstract

Background Private providers dominate health care in India and provide most tuberculosis (TB) care. Yet efforts to engage private providers were viewed as unsustainably expensive. Three private provider engagement pilots were implemented in Patna, Mumbai and Mehsana in 2014 based on the recommendations in the National Strategic Plan for TB Control, 2012–17. These pilots sought to improve diagnosis and treatment of TB and increase case notifications by offering free drugs and diagnostics for patients who sought care among private providers, and monetary incentives for providers in one of the pilots. As these pilots demonstrated much higher levels of effectiveness than previously documented, we sought to understand program implementation costs and predict costs for their national scale-up. Methods and findings We developed a common cost structure across these three pilots comprising fixed and variable cost components. We conducted a retrospective, activity-based costing analysis using programmatic data and qualitative interviews with the respective program managers. We estimated the average recurring costs per TB case at different levels of program scale for the three pilots. We used these cost estimates to calculate the budget required for a national scale up of such pilots. The average cost per privately-notified TB case for Patna, Mumbai and Mehsana was estimated to be US$95, US$110 and US$50, respectively, in May 2016 when these pilots were estimated to cover 50%, 36% and 100% of the total private TB patients, respectively. For Patna and Mumbai pilots, the average cost per case at full scale, i.e. 100% coverage of private TB patients, was projected to be US$91 and US$101, respectively. In comparison, the national TB program’s budget for 2015 averages out to $150 per notified TB case. The total annual additional budget for a national scale up of these pilots was estimated to be US$267 million. Conclusions As India seeks to eliminate TB, extensive national engagement of private providers will be required. The cost per privately-notified TB case from these pilots is comparable to that already being spent by the public sector and to the projected cost per privately-notified TB case required to achieve national scale-up of these pilots. With additional funds expected to execute against national TB elimination commitments, the scale-up costs of these operationally viable and effective private provider engagement pilots are likely to be financially viable.

Engaging Informal Private Health Care Providers for TB Case Detection: Experiences from RIPEND Project in India

“…For eliminating TB, it is essential to diagnose and treat all TB cases occurring in the community [ 3 ]. In countries like India, involvement of private health care providers is one of the quintessential processes to achieve TB elimination [ 4 ]. The private health sector comprises both formal and informal health care providers in almost equal proportions [ 5 ].…”

Enhanced Private Sector Engagement for Tuberculosis Diagnosis and Reporting through an Intermediary Agency in Ho Chi Minh City, Viet Nam

“…For example, risk-averse providers and those with a small caseload may have found the incentive to be insufficient to offset the risk exposure and expected value of penalties of un-notified TB treatment. These incentives may have also created inefficiencies whereby pulmonologists referred persons with TB through our study that would also have been referred in our absence as this level of incentive was high compared to traditionally paid amounts in Viet Nam [ 19 , 44 , 45 ]. Nevertheless, the costs of incentives paid by our study to detect a person with TB were a fraction of estimated total costs of detecting a new case through other systematic screening strategies [ 46 ] and warrant further optimization and evaluation.…”

Social Enterprise Model (SEM) for private sector tuberculosis screening and care in Bangladesh

“…The results of our assessment show the considerable impact that private sector engagement using new molecular tests and digital imaging can have in Dhaka: three facilities detected 37% of B+ TB notifications in an Asian megacity. Moreover, unlike many recent private sector engagement initiatives, the proportion of B+ TB case detection was quite high [ 12 , 28 , 29 ]. We also found high numbers of people with drug-resistant TB from the private sector.…”

“…The SEM improved TB and DR-TB cases notifications at a city level and helped to improve evidence-based TB management. This model, like others that use an interface agency to link the public and private sectors [ 12 , 13 ], is a useful method of broader engagement of the private sector for TB care, especially in Asia. The revenue generation aspect of this model may provide a sustainable solution in the TB response.…”

“…These modern versions of private sector engagement take much more active roles in the process, are initiated by non-public sector agents, and have often produced impressive results by vastly increasing the numbers of people tested and leading to improved numbers of TB cases detection, treatment and reporting to NTPs. Yet sustainability of these approaches are always an issue as they require major knowledge and behaviour change as well as enforcement which often is not possible due to lack of funding and governance [8,[10][11][12][13]. The delivery of any health services including TB services, public or private, requires funding.…”