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The paper reviews current understanding of the
behaviour and interactions of TB patients and private for-profit
providers, as a precursor to devising interventions for field testing
to win over the private practitioners and private voluntary organizations
to the DOTS strategy. India is a vast and heterogeneous country.
The location of the study sites are New Delhi, Agra, Jaipur, Lucknow,
Morena, 24 Parganas, West Bengal, Wardha, Bombay, Pune, Tumkur,
Madras, Bangalore, North-east which indicate that the available
information is representative of the whole country. Even then specific
local peculiarity cannot be excluded. The study period ranged from
1976 to 1996, most of them carried out in the 90s. In few instances,
the evidence was supplemented by interviews with knowledgeable experts
who had first hand information of the issues being discussed. The
findings of the review report are as follows: The prevalence of
TB is highest among male adults, belonging to low socio-economic
strata and tribals. The general public was found to be reasonably
aware of the symptoms of TB. Chest symptomatics are being found
to be 5-10% of the general population. The process of health seeking
behaviour of a TB patient is complex and may well last several years.
Most persons in India requiring curative treatment without hospitalization
choose private providers. People go to the nearest trusted health
care providers who is usually a private for-profit providers. The
poor and even in hilly areas choose them. Private practitioners
are perceived more sympathetic, more conveniently located, more
effective and more trusted for privacy than government run services
as having condescending doctors, substandard drugs, inconvenient
opening hours and long waiting times. However, once patients had
switched from private to government run providers, they become far
more appreciative of government-run services, drugs and staff. TB
patients health seeking behaviour is dependent of their symptoms.
About half of the TB patients seek help within a month, 50 to 80%
from private for-profit providers. Diagnosis of TB is often delayed
for weeks after first contact with a private provider. Almost 75%
of smear positive patients found in the care of private doctors
in mid-seventies were not being treated for TB. About half the patients
continue treatment with the private providers who diagnosed the
TB.
Most patients knew that they have TB even when
the providers try to conceal this stigmatizing diagnosis. They knew
that TB requires prolonged regular treatment. They start taking
drugs, but loose interest after relief specially the low-income
groups due to cost and inconvenience of taking drugs. With the passage
of time, work and social commitments increasingly displace the chore
of taking regular treatment. Even knowledge about consequence of
irregular treatment did not prevent it. As their funds get depleted
TB patients switch to government run services. The steady switching
from private to government run services is not matched by switching
from government-run to private providers. Except where DOTS is practiced,
do not achieve consistent cure. With DOTS, 80% cure rate was demonstrated
in pilot area while only 35% with standard regimen and 51.3% on
SCC completed treatment in NTP. As implied by these events, long-duration
patients accumulate in government-run services. Many TB patients
believe that TB carries a social stigma. Ex-TB patients are less
likely than average to find marriage partners in West Bengal. Unmarried
girls with TB fear that they might never find a spouse, those married
fears divorce. Women are typically less well placed than men to
ensure their own cure.
Out of pocket costs for diagnosis and successful
treatment in India are estimated at between 100 and 150 US Dollars
per patient as per 1992-1995 rupees dollar rates. However, individual
out of pocket expenditure on TB treatment dwarfs the substantial
sums expended by the government on the NTCP. However, private expenditures
on private TB treatment, which are estimated to exceed USD 150 million
per year, are typically rewarded by palliation rather than cure
of TB.
Over-diagnosis and over-prescription among private
for-profit providers are predictable. X-ray was found the test of
choice to rule out TB, with sputum examination done in only 10 to
20% of suspects. Treatment regimens prescribed were of 4 drugs intensive
phase with six months duration and were probably adequate to achieve
cure. Most of them prescribed anti-TB drugs and also gave expensive
diet supplements and alcohol based tonics.
Private practitioners generally keep no patient
records. Half of them admitted that they made no attempt to contact
patients who defaulted from follow up visits. Only 5% stated that
sputum negative smears were desired to call it a cured case. TB
patients do not form an important part of the business; only 1%
of patients seeking care at qualified allopathic provider while
one-third had no patients. TB Specialists might consider TB as an
importantpart of their business. Government services are normally
free, but waiting time, wages lost and drug unavailability impose
costs and inconveniences. Spot checks revealed that more than 50%
of PHCs had one or more TB drugs not available. Only 15% of the
patients knew that the treatment is free in government clinics.
On the whole, government-run health care services in India have
a poor image. The private for-profit health care sector plays a
major health care / system in India. In 1989, there were about 2,42,650
qualified allopathic physicians as compared to 88,105 in the government
services. The number of recognised hospitals in private sector grew
from 2,764 in 1983 to 4488 in 1987. The profile of a typical rural
private provider in Uttar Pradesh was a 38 year old male, with about
10-12 years of schooling, practicing a mixture of western and professional
medicines. Only 7% were qualified, while 90% learn the skills from
family members, or as compounders, pharmacist or as doctors
assistants. Nearly all the rural practitioners sell medicines by
margin added to the medications. About half of them were registered
with some medical association.
Drug retailers in India consistently sell restricted
drugs without requiring prescription. The legal and regulatory environment
for health care in India is in a state of flux. On paper fairly
well regulated but unregulated in practice. Consumer Protection
Council (CPC) in India has taken an active role in pursuing cases
of malpractice. However, CPCs role has been questioned by
the IMA and Supreme Court ruling.
Some important gaps in information persist. There
is no reliable estimate of the number, density and distribution
of specialist clinics where TB might form a more important part
of the case load. Several options for interventions have been identified.
Excluding TB drugs from private channels such as in Algeria and
Chile. Mandatory referral of TB patients to government-run services
such as in Oman. To run high quality and low costs to patients.
Involvement of private providers in the programme
by modifying the prescribing behaviour by academic counseling. In
any case complete regular treatment and standardized monitoring
promise a greater improvement than changes in prescribing alone.
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