Public-private-partnership needs under the National Tuberculosis Elimination Program in an Eastern Indian state

Eliminating tuberculosis (TB) is among India's top public health priorities[1]. Despite the considerable progress in providing quality TB care services, the Global TB report-2022 reveals that India is amongst the eight high TB burden countries that contributed to more than two-thirds (68.3%) of the global TB cases[2]. To strengthen and aid the TB elimination efforts by 2025, five years ahead of the sustainable development goal target, the Government of India, under the program, promotes intersectoral convergence with various public sector departments and the private sector. The national multisectoral action framework for TB-free India promotes private-private or public-private partnerships for sustainable and impactful Corporate Social Responsibility initiatives[3]. In addition, the Partnership Guidance Document-2019 developed by the Central TB Division, Government of India advocates the effective engagement of the private sector through procurement of services and contracting with the service providers/private agencies (both for-profit/not-for-profit) for the entire cascade of TB care. To cover the cascade of TB care, the document offers eight different partnership options that can be achieved through effective contracting with the service providers. The suggested partnership options are: (1) patient provider support agency, (2) public health action, (3) specimen management, (4) diagnostics, (5) treatment services, (6) drug access and delivery services, (7) active case finding and TB prevention, and (8) advocacy communication and community empowerment[4]. Furthermore, the National Strategic Plan (NSP) outlines the necessity of transforming the program's current approach to include private providers which should be large-scale and systematic instead of ad hoc and insignificant[5]. There have been several attempts to engage the private sector in the efforts to eliminate TB in the country. The Central TB Division (CTD) created the first partnership guidelines in 2001 and revised them in 2008 and 2014 for the participation of non-governmental organizations (NGOs). These guidelines aimed to increase the engagement of NGOs and private sector providers to include all patients[4]. Additionally, the National TB Elimination Program has already collaborated, albeit with differing degrees of success, with a few NGOs and medical colleges via grant-in-aid methods. A large-scale, long-term and sustainable engagement of the "for-profit" private health sector was primarily lacking from these interventions. Nevertheless, data from recent large-scale pilots, like the Patient-Provider Support Agency (PPSA), has shown how contemporary approaches of including the private sector can produce outcomes with a significant impact[6]. To carry out a public-private-partnership needs assessment in the state of Odisha, a two-step process was followed in which a desk review of key performance indicators was carried out as a first step to come up with plausible partnership options corroborated by primary data. The assessment was carried out during the second quarter of 2023 with the support of the officials of the state TB cell and district TB cell of the concerned districts. Notification, microbiological confirmation, drug sensitivity testing, HIV testing, diabetes testing, and treatment outcomes were used as important performance indicators, as suggested in the partnership guidance document-2019. Five years of data (2018-2022) were retrieved from the Nikshay portal and were graded every year and a five-year cumulative grade was assigned to each of the key six performance indicators. Following the desk review, the district officials were interviewed in which the officials expressed the need to have different partnership options. Two districts expressed the need for a patient-provider support agency and active case finding, three districts expressed the need for advocacy communication and community empowerment and one district each expressed the need for specimen management and diagnostic services as the partnership option. The partnership guidance document-2019 suggests that the private sector needs assessment must be carried out every year by the program managers and the needs must feed into the program implementation and planning (PIP) of the National Health Mission[4]. This needs assessment was carried out as a pilot assessment across four districts of Odisha and the needs were incorporated into the PIP. The gap in notification provides scope for improved private-sector engagement, for which the PPSA is one of the modalities which, apart from improving notification, can also take care of the extended public health action of the private sector patients. Aligned with the national strategic plan, the PPSA model has contributed to improved treatment quality for patients utilizing the private sector, decreased out-of-pocket expenses for drugs and diagnostics for TB care, and strengthened the health system to enable universal access to TB care. These agencies provided the patients access to the full range of TB services. The PPSA proved that locally tailored, low-cost private sector engagement strategies with robust administrative support are both workable and beneficial to the community. Furthermore, by customizing a collaboration and monitoring framework, the Joint Effort for TB Elimination Initiative, a private provider support agency, aided in the development of sustainable processes for private sector engagement. It is predicated on the profitable customer care services provided by the private sector in conjunction with its social responsibility, and on the government's actual involvement in providing TB services to the entire population, including those who seek care in the private sector. Because it benefits the patient, the National TB Elimination Program, private hospitals, and society as a whole, it is easily scalable and reproducible[7]. In addition, studies in some states have also demonstrated that PPSA has significantly improved private-sector TB notification[8]. Furthermore, the notification gap can be addressed through increased case detection which can be leveraged through various demand-generation activities such as Advocacy Communication and Social Mobilization[9]. At the same time, Active Case Finding is a very significant complementary strategy to improve case detection in many vulnerable communities[8]. Additionally, Active Case Finding is a good strategy, epidemiologically and economically, as it can bring down the level of transmission if linked effectively with diagnostic and treatment services. Moreover, low scores in treatment success rates can be addressed through appropriate public health action in the private sector. As per the partnership guidance document-2019 “public health action” is a set of services for private sector TB patients that includes counselling and adherence management, contact tracing and chemoprophylaxis, HIV counselling, testing and treatment linkage, drug susceptibility testing and linkage for DR-TB services, blood sugar testing and linkages for diabetic care, linkages for Nikshay Poshan Yojana. All these services could be bundled together or a combination of a few of these services could be provided as a set of services under “public health action”. Similar interventions have been carried out in India and proved effective for private-sector patients[10]. However, in hard-to-reach areas, low treatment success rates can also additionally be addressed through drug access and drug delivery services with improved public health action[11,12]. Gaps in diagnosis indicators can be addressed through diagnostic services[13] and in the case of tribal and hard-to-reach areas, there might be a requirement for improved specimen management services. It is well understood that for TB elimination efforts, private sector engagement is one of the strongest links in two different ways: one way is that the private providers can directly help patients in diagnosis and treatment which is more direct and the other way is with engagement of various non-governmental and civil society organization as partners of service delivery walking hand-in-hand with the government in which they can deliver any of these services delineated above. The needs assessment must be conducted before the PIP so that the same can be included on time. The program manager must carry out the assessment every year as suggested in the partnership guidance document-2019. The assessment was carried out in 4 pilot districts of the state which can further be extended to other districts as the same can facilitate feeding into the PIP. Furthermore, given the complexity of the program, it may not be possible to understand all the granular details of each of the indicators under the program. Assessment of these indicators would largely depend upon the resources, timeline and feasibility of conducting similar assessments under practical situations. Conflict of interest statement The authors declare that there are no conflicts of interest. Funding The authors received no extramural funding for the study. Authors’ contributions JS designed the concept of the study and conducted the literature review. JS and AM conducted the data analysis and prepared the manuscript. JS contributed to the final editing and review of the manuscript. 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