Existence of public medical facilities does not ensure their acceptance contrary to what was assumed by the NTP. Besides their limited research in the whole community, their case-holding is marred by defaulters. Defaulters are not necessarily the poor and the underprivileged, but are as likely to be those who indulge in medical consumerism out of consideration of status. To secure better case finding and case holding, involvement of private medical practitioners is suggested along with possible means of enlarging the "catchment area" of the DTC, like identifying special target referrals can be encouraged selectively, and emphasizing the superiority of routine diagnostic and curative activities of the DTC vis-a-vis private practitioners, so as to give a sociological "face lift" to the DTP, which will attract more of those patients who pay more, and get less, from private practitioners.

This study of 81 rural and 96 urban private medical practitioners, which included 67 allopaths and 110 nonallopaths, was conducted to understand how patients of lung TB are diagnosed and treated in their clinics as well as their interactions with and perceptions regarding the public health services available for TB control. A majority of private doctors gave little importance to sputum examination and considered X-ray of the chest as the single most important diagnostic test for lung TB. They were neither aware of nor employed inexpensive standard regimens for treating their patients. While all private doctors used SCC in the treatment of lung TB, few regimens used by them conformed to the ones recommended under the NTP. Private doctors were aware of but sceptical about TB treatment available at public health facilities.

This study is conducted in Rural and urban areas of Maharashtra, a large state in Western India. to understand TB management practices among private medical practitioners (PPs) and the treatment behaviour of the patients they manage.

Prospective study of help-seeking patterns and treatment behaviour among 173 pulmonary TB patients diagnosed in private clinics, and the TB management practices of 122 PPs treating these patients.

The first source of help for 86% of patients was a PP. The diagnostic and treatment practices of PPs were inadequate; 15% did not consider sputum examination to be necessary, and 79 different treatment regimens were prescribed by 105 reporting PPs. Sixty seven percent of the patients diagnosed in private clinics remained with the private sector, and the rest shifted to public health services within six months of treatment. The treatment adherence rate among the patients in private clinics was 59%. There were discrepancies between the reported management practices of the PPs and what their patients actually followed.

The study identifies and highlights the need to educate PPs and their TB patients, and indicates ways in which PPs could be meaningfully involved in efforts to revitalize the NTCP.

Enlisting co-operation of TB patients in adhering to the prescribed drug regimen, dosages, regularity of drug intake and completion of treatment, under the condition of a private medical practice in India is of topical interest.

It is a common belief that private medical practitioners do not take adequate efforts to offer organized medical care to TB cases due to various reasons. The study was undertaken by a private medical practitioner himself to highlight the TB treatment management under a private medical practitioner. Of the study cohort of 307, 20-25% were from Bikaner city, another 25-30% from Bikaner district, rest were from neighboring districts. Of the total patients, 211 comprised of newly diagnosed and 96 of previously treated patients. They were all registered at the author’s private clinic from 1st Oct 1991 to 31st Dec 1995.

The SCC regimen chosen was 2EHRZ/4HER/3HR and self-administered at home. The regimen and the frequency of monitoring check up in the present study are somewhat different from those recommended under the NTCP. Around 20% of the expected irregularity in drug intake was sought to be covered by prolonging the treatment period from 6 months to 9 months so that each case has the best chance of completing at least 7 months treatment in 9 months. Great care was taken that patients take at least 3 drugs in the initial phase of 2 months.

Personal motivation was given by the private practitioner to the patient and/or family members at each visit and monthly visits which helped the practitioner to maintain a good level of health education and establishing motivational support with patients.

Patient co-operation during the study was quite satisfactory. More than 2/3 of the patients were regular in coming to the clinic. As told by the patients at the time of follow up visits, upto 80% had taken their treatment regularly for 7 months or more in 9 months. There was hardly any difference between the newly diagnosed and previously treated patients in this regard. Of the 307 patients in the cohort 244 (80%) were available for assessing the efficacy of treatment at the end of 9 months. The bacteriological conversion among those previously treated and newly diagnosed was 85% and 90% respectively.

This study demonstrates that a Private Medical Practitioner with minimum infrastructure too can provide anti-TB drug delivery and regular motivation at clinic without difficulty. Therefore, satisfactory results obtained comparable to any good public sector control programme are due to good services provided by the practitioner. Adherence to treatment was the same in both previously treated and untreated cases which suggests that if a reasonable care is provided, the previous poor experience is no bar to enlist co-operation to get good results.

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.