From Pilots to Systems (Part 2): Achieving systemic and scalable private sector engagement in tuberculosis care and prevention in Asia
Dr. Mukund Uplekar and Madhukar Pai also contributed to this article, which originally appeared on PLOS Medicine.* This is the second of two parts; in Part 1, the authors described the public-private mix (PPM) as a method of addressing some of the unique challenges in tuberculosis treatment, and how PPM is being used to replace low-quality and potentially expensive health care with rapid, affordable and correct diagnosis and treatment, and monitoring to ensure success.
When TB treatment providers are already well connected to the broader health system, and can be reached as a group, the task of engagement is more manageable.
For example, some of the quick wins in the public-private mix world have come from hospital and medical college engagement. With large patient flows that include many people with TB symptoms, hospitals constitute a substantial unit for engagement. A directly observed treatment short-course (DOTS) clinic in a hospital can do TB reporting and defaulter tracing for the entire hospital – and indeed, for surrounding private providers – and the hospital administration can disseminate new policies and practices to all staff. This has allowed hospitals to contribute up to 10 percent and 50 percent of case detection in parts of the Philippines and Indonesia, respectively.
However, outside of these settings, the numbers become more challenging. India has more than 750,000 chemists and pharmacists; most see only a handful of people with TB symptoms a week. For a traditional PPM scheme, each one of these providers needs to be visited individually by either the public-sector TB worker or the intermediary organization.
The PPM intermediary organization is, however, the beginning of an organizing or consolidating force in an otherwise fragmented health care system made up of individual private providers. The intermediary organization networks providers in order to take part in education, reporting and regular supervisory visits. Tactics have varied: Bangladesh schemes focus on reaching as many providers as possible, but with a relatively informal (verbal) referral system, whereas schemes in Cambodia use triplicate referral forms.
Intermediary organizations can benefit from performance-based financing, in which payment is not for inputs but for outputs such as case notifications or cures. Although misaligned incentives are possible, in general this encourages optimization. An example is India’s urban pilot of private-provider interface agencies (PPIAs), which use a basket of services for privately treated patients, such as vouchers for free TB tests and drugs. The PPIAs make maximum use of information technology such as mobile phones, call centers, electronic notifications and drug vouchers, and linkages with universal ID numbers or large databases for social security. These mechanisms make it possible to educate and maintain contact with the large number of providers, notify cases to the national TB programs (NTP) and help with patient follow-up (see the Revised National Tuberculosis Control Programme: “National strategic plan for tuberculosis control, 2012–2017”). In PPIAs, private providers can retain their patients and even offer several value-added services.
Consolidation of private laboratories by an intermediary agency is also feasible. The Initiative for Promoting Affordable and Quality Tests (IPAQT) in India provides more than 100 accredited laboratories with concessionary pricing in exchange for their case notification to the NTP and passing on the price reductions to patients for WHO-endorsed TB tests.
These various types of PPM schemes can clearly boost TB case detection and treatment outcomes. In 2013, PPM with private-sector providers alone yielded 14 percent of all TB notifications in Ethiopia, Nigeria and Pakistan, 15 percent in Tanzania, 20 percent in Myanmar and 21 percent in Kenya. Intermediaries were most often NGOs but also included professional associations (e.g., in Myanmar and Indonesia) and social franchise organizations (in Myanmar and Pakistan).
However, as economies grow and TB incidence drops, it will be more and more difficult to sustain interest and funding for such TB-only schemes. We need to look for new ways to promote the connection of individual health care providers to each other and to networks and systems in the broader health system, and for opportunities to include TB in any cross-cutting initiatives on health care consolidation, rationalization and organization.
Economic Growth and More Sustainable Opportunities
If it is the atomization of the health care system that is PPM’s biggest challenge, then economic growth is bringing some potential solutions. Since 1950, 13 economies have grown at an average of 7 percent or more for 25 years or longer, and many other countries are on an earlier but similar trajectory. The resulting changes in health financing will bring changes in health systems overall and in the opportunities for engaging private providers.
Social franchises or social businesses provide one possible structure for this engagement. These schemes still fall under the category of intermediary organizations, as noted above. However, they combine their programmatic goals in public health with business structures and aim to move, ultimately, beyond a project status and into the territory of a self-sustaining business. Rather than focusing only on what the public sector “needs” and what the private sector “should” do, these organizations aim for a logic that works for the private entity itself. Integration of multiple disease areas is a critical characteristic of these initiatives: Non-TB indications may provide greater patient volumes and prove a greater draw for providers, but TB is included as a requisite part of the business model.
Income from these businesses could in theory lead to sustainability, but there are two major concerns. First, the amount of this income is currently far from sufficient to cover the total operating expenses. Presumably, financial flows may increase as economies develop. But second, the income is almost entirely from out-of-pocket expenditures by patients – a problem for low-income communities in which TB is most prevalent. In the future, social franchises and businesses could make ideal recipients for results-based financing from governments and for payments from growing national health insurance (NHI) schemes.
Results-based financing has been tried both by funding agencies and by governments for disbursement of their own money, but governments can be reluctant to directly fund private-sector entities with domestic resources. Thus, there has been limited work on creating efficient, results-based pathways from governments to private providers.
By contrast, many countries have growing NHI schemes aimed at both public and private providers; these are an integral component of their push toward universal health coverage (UHC) and will be a critical factor in future engagement of private providers.
A number of NHI schemes have reimbursements for TB, including for TB treatment by private-sector physicians. The schemes may be a two-edged sword: Public TB programs may struggle to secure alternative financing to maintain certain essential public health functions even as the private sector finds itself with a more stable, self-sustaining income stream for private-sector TB treatment. In addition, NHI schemes often start by covering people with formal employment, who are typically richer and thus at a lower risk for TB.
Many of the teething problems with these schemes relate to the extra administrative burden, which may bring enrollments or reimbursements to a halt, thus removing the incentive to participate in the insurance scheme. However, it is this very administrative effort (combined with information technologies) that is linking together providers and thus providing the structure and opportunity for PPM. These are promising experiments worth watching.
Can the processes inherent in health insurance schemes address the TB quality issue? Theoretically, NHI schemes could include payments to private providers for certain desirable objectives, such as TB treatment completion. However, the field lacks the microeconomic analysis of providers to help guide the design of such incentives. In addition, most TB treatment occurs in a primary health care setting in which providers are paid based on caseload (capitation) rather than specific procedures. This makes it difficult to tie payment to specific diagnostic and treatment behaviors.
However, several countries are experimenting with an interesting combination of regulation and insurance. For example, enrollment of providers in the NHI scheme, and continuing reimbursements, can be made contingent on achieving certain accreditation or licensing requirements, including laboratory standards, further education on TB standards or prompt reporting of TB cases. The latter requirement also needs an efficient (meaning, usually, electronic) system for mandatory notification.
With economic growth, the low-quality, informal private medical sector generally tends to diminish, and health services become more organized in other ways. The establishment of large private pharmacy chains in the Philippines (see the Philippines National TB Program (2013): “Review of the national tuberculosis control program”) and lab networks in India are examples of this trend; market-based interventions can encourage this process. As with the hospital example above, this reduces the number of distinct entities that need to be engaged by TB organizations.
Evolution of Health Workforces
PPM highlights some difficult choices that need to be tackled in developing health systems. One of these issues is dual practice. In many low-income settings in Asia, the public-sector salaries for health care workers are insufficient to sustain a family. Therefore, the doctor or pharmacist practices in the public sector for a few hours, and the remaining time is spent in private practice. Such a pattern holds for an estimated 90 percent of doctors in some of these countries.
Such a system certainly constitutes an unhealthy linkage between public and private, as it sets up some unfortunate dynamics, and dual standards of care. Public-sector doctors have an incentive to provide substandard service or to neglect certain essential public-sector services, such as X-rays, so that their private practice will get more referrals. In addition, when the doctor or pharmacist is working in the public sector, their private business often stays open. During these times, in the absence of the qualified provider, drugs and advice are typically dispensed by unqualified relatives or employees. Broader solutions, such as realistic, performance-based compensation in the public sector and regulation of dual practice, will be an integral part of PPM solutions.
Toward a More Systemic and Scalable PPM
PPM is moving from pilots to widespread implementation and is contributing to a larger percentage of TB notification and treatment. But scale, sustainability and affordability remain a major concern. In the meantime, new opportunities have arisen in the form of social businesses, national health insurance schemes, payment reform, regulatory regimes, information technologies and consolidation of other health care structures. All these efforts in TB are highlighting the complex policy choices that lie ahead and are providing the motivation to tackle initiatives that will benefit the entire health sector.
William Wells is employed by the U.S. Agency for International Development and Dr. Mukund Uplekar is a staff member of the World Health Organization. The views expressed in this article do not necessarily represent the views of these organizations.
* Originally published as “Wells WA, Uplekar M, Pai M (2015) Achieving Systemic and Scalable Private Sector Engagement in Tuberculosis Care and Prevention in Asia. PLoS Med 12(6): e1001842. doi:10.1371/journal.pmed.1001842”