TF-6: Accelerating SDGs: Exploring New Pathways to the 2030 Agenda
With the implementation of the Sustainable Development Goals taking centre stage as 2030 nears, it is imperative to look at models to engage the private sector in healthcare delivery. India’s National Tuberculosis Elimination Program (NTEP) has taken a lead in mobilising the private sector, using a patient-centric approach to manage tuberculosis (TB). The Indian TB elimination model allows patients in the private sector access to government-sponsored drugs and diagnoses. Taking a holistic approach, NTEP works with local organisations to map and engage private healthcare providers, pharmacies, and diagnostic centers in a common effort to tackle the spread of TB. Patients are also offered diagnostic services and medicines free of cost. This private sector approach to dealing with TB is aligned with the major aspects of urban primary healthcare and is flexible, innovative, and adaptable. At the same time, because of its primary healthcare–oriented foundations, this partnership model offers a service delivery solution that can also address a wider range of essential health service issues and be successfully used for dealing with other infectious diseases.
1. The Challenge
Achieving health-related Sustainable Development Goals (SDGs) requires concerted efforts at a global level, especially in the wake of the COVID-19 pandemic, which continues to derail the progress made thus far. The United Nations General Assembly has endorsed a resolution urging countries to accelerate progress toward universal health coverage.[1] Mixed healthcare models, consisting of both public and private healthcare providers, are increasingly becoming a characteristic feature of healthcare systems around the world.[2]
The private sector in health is a heterogenous group consisting of hospitals, single window clinics, pharmacists, and informal medical care providers, among others. Engaging the private sector in the fight against tuberculosis (TB) is critical to achieving the targets outlined in SDG3. Growing economies around the world face a unique challenge in terms of enlisting the private sector in these efforts. This is particularly critical because private players cater to a substantial chunk of the healthcare needs of the population. It is, therefore, important to look at models of engaging with private sector entities within the G20, which can be scaled-up to address countries’ health priorities. One such model has emerged in India, where the government has successfully engaged the private sector in accelerating its progress towards ending tuberculosis. Even though TB is one of the oldest known diseases, apart from COVID-19, it is still the leading cause of death from a single infectious agent. The World Health Organization suggests close to 10.6 million people contracted TB and 1.6 million people died of it in 2021 alone.[3] India has made great strides in controlling TB and is one of the three countries that contributed to considerable relative reductions in annual TB case notifications in 2021 as compared to 2019. Yet, India still accounts for 26 percent of the global TB burden and reported 2.42 million TB cases in 2022.[4]
India has a large private health sector, with 80 percent of the qualified personnel[5] and 60 percent of health expenditure coming from the private sector.[6] There are several issues in the TB treatment offered by the private sector, such as delayed diagnosis, suboptimal quality of care, lack of systems for tracking treatment adherence, and minimal patient support. These lead to a high rate of treatment dropout. Therefore, working with the private sector is critical for ensuring quality TB care. India’s commitment to engaging the private sector can be gauged from its target of achieving 1 million plus private sector TB notifications in the year 2020 and 2021.[7] As per analysis done by NTEP, between 2012-2018, approximately 47 percent of TB notifications were from individual clinics, 48 percent from private hospitals/medical colleges, and 5 percent from pharmacists.[8]
Solution
India’s national tuberculosis programme, National Tuberculosis Elimination Program (NTEP), recognised that private sector engagement is important to accelerate the progress towards ending TB as public health challenge. While the NTEP took steps to engage the private sector before 2013-14 as well, these achieved limited success primarily due to design gaps, conflicting market forces and other factors. Through the Universal Access to TB Care project, the aim was to improve TB notifications by offering healthcare providers user-centric information and communication support along with TB diagnostics, medicines, and adherence support. The NTEP, supported by partners, designed models to allow TB patients in the private sector to get access to free public-sector drugs and TB diagnoses via a third-party interface agency. Between 2013 and 2017, government institutions (like Central TB Division (CTD), Government of India, and local governments) along with partners like PATH and World Health Partners implemented pilot projects in Mumbai and Patna, that demonstrated the importance of Public–Private Interface Agencies (PPIAs) in engaging private healthcare providers. These interface agencies mapped and subsequently engaged with private healthcare providers on behalf of the national TB program to provide high quality diagnostics to individuals with symptoms suggestive of TB, to report confirmed TB patients to the program, and to provide patients anti-TB drugs and all the necessary support for adherence to treatment. Diagnostic services and drugs were provided free of cost to TB patients. Subsequent evaluations of PPIA pilots in Mumbai and Patna found significant reductions in durations and delays in accessing care[9] and were also found to be cost-effective.[10] It is important to mention here that besides the pilot, the government has also introduced regulations like the mandatory reporting of TB cases[11] and the insertion of anti-tuberculosis medicines under schedule H-1 of the Drugs and Cosmetics Rules, 1945.[12] The latter requires that a seller must record the details of the prescriber and the patient and cannot sell anti-TB drugs without a registered practitioner’s prescription.
Figure 1: Visual representation of the PPIA model.
Source: PATH
Subsequently, with support from the Global Fund, the pilots were scaled across other geographies in the country in the form of the Patient Provider Support Agency (PPSA) model, as part of Project JEET (Joint Effort for Elimination of Tuberculosis).[13] In the recent past, the World Bank has supported the Government of India in institutionalising private sector engagement work with a particular focus on 9 high burden states.[14] The CTD has approved PPSAs in 385 districts with an interface agency onboarded in 188 districts.[15]
Interestingly, the NTEP has engaged these interface agencies on a pay for performance basis, making it easier for patients to get the correct diagnosis and timely treatment. Via the pay for performance model, the NTEP seeks to expand partnerships beyond not-for-profit organisations and induct for-profit providers including social/health sector entrepreneurs. By focusing on performance outcomes and delivery of high-quality services, the NTEP aims to build successful third-party partnerships.[16] Owing to the efforts mentioned above, the private-sector contribution to TB notifications increased from 7 percent in 2014 to 30 percent in 2022[17]despite the impact of COVID-19 on essential health services.
While the PPSA model has proven its relevance for TB control in high burden geographies, there are some aspects of it that need further strengthening. Timely payments to providers and agencies have been a challenge,[18] along with the training needs of health officials and partner agencies to monitor and implement tasks.[19] Contract management, to a large extent, is done manually, despite the existence of a robust patient-based ICT system. While the new partnership guidance released by the CTD opens the door for social enterprises, start-ups, and for-profit private entities, the PPSAs are largely limited to not-for-profit, non-governmental organisations.
The need to engage the private sector is well established owing to several factors such as, a high demand for primary healthcare for underserved populations, an urgent requirement for the regulation of private healthcare providers, a need for the private sector to complement public healthcare services, and finally the necessity to create an innovations hub.[20] The NTEP in India has taken a lead in harnessing the private sector for a patient-centric approach. The COVID-19 pandemic has shown the importance of engaging the private health sector. Public health challenges like anti-microbial resistance are a growing concern. In some of the G20 countries, more than 40 percent of infections are resistant to some antibiotics.[21] The private health sector also has a skewed distribution, with a large concentration in urban areas, with people from across different wealth quintiles preferring private healthcare. As countries firm up their action plans for addressing such challenges, there will be a need to create pathways to engage the private healthcare sector, which is the first point of care in many of these countries.
2. The G20’s Role
As mentioned in the SDGs, countries aim to end the tuberculosis epidemic by 2030. The current progress towards achieving this target suggests that a multisectoral global push will be required rather than limiting the response to individual countries alone. The G20 is composed of the world’s major economies and the member countries contribute to 85 percent of global GDP, 75 percent of international trade, and two-thirds of the global population.[22] Close to 50 percent of the estimated global TB burden is in G20 countries, with 5.33 million out of 10.56 million people that contract TB being from the G20 countries.[23] In 2021, only sixty percent of the 10.56 million people estimated to have caught TB were diagnosed and treated. Half of these ‘missing’ 4 million cases twere from G20 countries. In 2017, G20 leaders recognised the need to combat anti-microbial resistance, including in tuberculosis cases.[24] The Indian government has stated its plans to use its G20 presidency to build consensus on a global health accelerator[25] which could prove to be a boon for TB control efforts around the world. A recently published report suggests that investing in TB control measures has high returns with every US$ 1 invested in TB control yielding US$ 46 in benefits.[26] Evidence suggests that in low-income countries, TB results in the highest losses to labour supply and household income.[27] Thus, investing in SDG3 to end tuberculosis has significant economic payoffs, resulting from increased productivity. The G20’s proactive actions on steering the TB control efforts among member and and non-member countries alike can compound the efforts to end tuberculosis as a public health challenge and contribute to the resulting economic benefits.
The G20 plays a major role in shaping public health priorities. With TB, especially multi-drug resistant TB, being a significant health security challenge in many G20 countries, the learnings from India’s TB program can be useful for the grouping and beyond. While there are country specific variations, 21 of the 27 high-income EU countries have a majorly private sector owned primary healthcare system.[28] The private health sector also provides over 50 percent of all healthcare in Sub-Saharan Africa and over 80 percent of all healthcare in Asia.[29] Many of the G20 member countries have a big private sector in health and there is a significant need for the G20 to shape up policies around private sector engagement in health.
3. Recommendations to the G20
In the year that India holds the G20 presidency, it has the largest burden of tuberculosis in the world. It is also worth noting that the upcoming G20 presidencies, Brazil (2024) and South Africa (2025) are all high TB-burden countries. There can be no better time to demonstrate actionable and impactful work towards promoting health. The G20 can act as a catalyst towards enhancing global action on key health challenges facing the world today. Below are a few key recommendations for the G20 based on the learnings from India:
- Invest urgently in scaling-up successful private sector engagement models in health systems not only in G20 member countries, but also globally. Many G20 countries have mixed health systems and require their governments to scale-up private sector engagement models like PPIA/PPSA. Earmarking budgets for private sector engagement is important. India’s National Strategic Plan for TB Elimination 2012-17, recommends earmarking 30 percent of a public-private mix budget for piloting innovations. Other countries could consider India’s recommendations based on the size of their respective private sectors and their burden of TB.
- Establish a framework for health information systems that can gather and analyse updated information on private providers. This will address the need for accurate information on the size and type of private providers and support tailor-made strategies for private sector engagements. This will also enable the engagement process for not only TB, but other health conditions as well.
- Advocate for cross-G20 partnerships and facilitate shared learnings on strategies to engage the private sector in health. Creating knowledge networks that target the contextual needs of mixed health system countries could aid public health practitioners around the world. Multi-sectoral collaborations are needed to address complex health challenges being faced by countries.
- Priortise and speed up actionable progress on the G20’s 2017 commitment to combat AMR, including multi-drug resistant tuberculosis, with particular attention paid to the private sector. TB control needs to be executed with a ’whole of government’ approach, with its progress being monitored at the highest level of the government.
- Improve the regulatory capabilities of countries to steer their private health sectors in tandem with their public health goals and priorities. Policy options like mandatory notification and prohibition and monitoring of the sale of anti-TB drugs could be considered by other countries.
- Increase investments and collaborate on R&D for a more potent adult TB vaccine accessible to all individuals at risk of tuberculosis, irrespective of their place of residence. Promote technology transfer between countries to ensure that critical med-tech and digital innovations like vaccines and molecular diagnostics can be accessed locally.
Attribution: Mayank Sharma et al., “Engaging the Private Sector for Health SDGs: Lessons from India’s National Tuberculosis Elimination Programme,” T20 Policy Brief, August 2023.
Endnotes
[1] United Nations, “International Universal Health Coverage Day,” accessed June 12, 2023.
[2] World Health Organisation, “Private Sector Landscape in Mixed Health Systems,” December 7, 2020.
[3] World Health Organization, “Global Tuberculosis Report 2022,” October 27, 2022.
[4] Ministry of Health and Family Welfare, “India TB Report 2023,” March 2023.
[5] Srinadh Ranganadham, “Morbidity, Health-Seeking Behaviour and out-of-Pocket Expenditure among Large Indian States,” NITI Aayog, Accessed June 7, 2023.
[6] Ministry of Finance, “Government Health Expenditure in Total Health Expenditure Increases from 28.6 per Cent in FY14 to 40.6 per Cent in FY19,” Press Information Bureau, Accessed June 12, 2023.
[7] Central Tuberculosis Division, “Dashboard: Ni-Kshay Reports,” Accessed June 6, 2023.
[8] World Bank, “Private Sector Engagement for Tuberculosis Elimination: India’s Journey from Pilots to National Scale-Up (2012–2021),” 2023.
[9] Sanchi Shah et al., “Effect of Public-Private Interface Agency in Patna and Mumbai, India: Does It Alter Durations and Delays in Care Seeking for Drug-Sensitive Pulmonary Tuberculosis?” Gates Open Research 4 (2020): 32.
[10] Nimalan Arinaminpathy et al., “Engaging with the Private Healthcare Sector for the Control of Tuberculosis in India: Cost and Cost-Effectiveness,” BMJ Global Health 6, no. 10 (October 1, 2021): e006114.
[11] SB Nagaraja et al., “Extending Tuberculosis Notification to the Private Sector in India: Programmatic Challenges?,” International Journal of Tuberculosis and Lung Disease 18, no. 11 (November 1, 2014): 1353–56.
[12] Ministry of Health and Family Welfare, “Rules for Selling of Drugs under Schedule H1,” Press Information Bureau, May 10, 2023.
[13] Project JEET, “Joint Effort for Elimination of Tuberculosis,” May 9, 2023.
[14] World Bank, “US$ 400 Million World Bank Loan to Help Treat and Eliminate Tuberculosis in India,” World Bank, September 30, 2019.
[15] Ministry of Health and Family Welfare, “India TB Report 2023,” March 2023.
[16] Central Tuberculosis Division, “Guidance Document on Partnerships,” October 28, 2019.
[17] Central Tuberculosis Division, “Dashboard:Ni-Kshay Reports,” Accessed June 12, 2023.
[18] Sanjeev Nair et al., “Barriers for Involvement of Private Doctors in RNTCP – Qualitative Study from Kerala, India,” Journal of Family Medicine and Primary Care 8, no. 1 (January 1, 2019): 160.
[19] PATH, “Tuberculosis Elimination in India: What’s next for Private-Sector Engagement?” March 2022.
[20] World Bank, “Role of Private Sector Engagement in Reimagined Primary Health Care Delivery: Comprehensive Review,” World Bank, June 2020.
[21] Organisation for Economic Cooperation and Development, “Stemming the Superbug Tide,” OECD Health Policy Studies, 2018.
[22] G20, “G20 – Background Brief”, October 31, 2023.
[23] Stop TB Partnership, “The G20,” May 10, 2023.
[24] World Health Organization, “G20 Leaders Make Historic Commitment to Combat AMR and TB in Declaration,” 17 July, 2017.
[25] World Economic Forum, “India Plans to Use Its G20 Presidency to Build Consensus on Global Health Resilience,” May 16, 2023.
[26] Copenhagen Consensus Center, “Halftime for SDGs: Tuberculosis,” February 2023.
[27] Jaana Remes, Matt Wilson, Aditi Ramdorai, “How Investing in Health Has a Significant Economic Payoff for Developing Economies,” Brookings, July 21, 2020. 27.
[28] Organisation for Economic Cooperation and Development, “Health system characteristics survey 2010 and OECD Secretariat’s estimates,” 2018.
[29] Health Systems Global, “The Private Sector,” May 2022.
