b) Measures to Improve Treatment Adherence
AU : Pathania V, Almeida & Kochi A
TI : TB patients and private for profit health care providers in India
SO : WHO/TB/97. 233
DT : Per
AB :

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 patient’s 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 doctor’s 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, CPC’s 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.