Kamal Kant Sharma, Research Manager, Ashish Sachdeva, Research Director & Adjunct Assistant Professor and Sirisha Papineni, Research Consultant from Max Institute of Healthcare Management (MIHM), Indian School of Business (ISB), India highlight that India should reduce disruptions and incorporate sustainability components into the private sector tuberculosis (TB) care model “Patient Provider Support Agency” (PPSA) to achieve the target of TB elimination in the country

India bears 28 per cent of the global TB burden and accounts for 36 per cent of TB-related deaths (1). Despite the care available in the public sector, 50-80 percent TB patients initially seek healthcare in the private sector (2,3). However, the quality of private-sector TB care often falls short of global standards due to inadequate care coordination across the diagnostic and treatment cascade (4,5,6).

In 2018, a Patient-Provider Support Agency (PPSA) model was initiated in 105 districts across India to bridge the difference in care delivery between the public and private sectors (7). The PPSA model uses a private agency to provide support services including diagnostics, free anti-TB drugs, patient adherence and support, and referral linkages (8,9). PPSA agencies are frequently contracted for short terms. When these contracts end, the associated infrastructure and human resource support often disappear, leaving providers and patients to manage their care. As of 2022, the PPSA model was approved in 385 districts, out of which services were operational in 188 districts (10).

As part of a larger study on TB care in the private sector, a team from ISB Max Institute of Healthcare Management (ISB MIHM) at the Indian School of Business (ISB) conducted visits to seven districts in the Indian states of Punjab, Haryana, and Jharkhand. These districts were previously linked to PPSA agencies, but their services had recently terminated. The team interacted with 27 physicians in private clinics, 23 patients, 18 pharmacists, and 11 public health workers, and made the following observations on the current private-sector TB practices:

On the providers’ side, we observed that 21 private providers halted the augmented TB services upon termination of PPSA contracts citing heavy workload, manpower shortage, supply chain challenges for free TB drugs, and insufficient guidance and support for independent service sustainability. In contrast, six physicians took independent initiatives to uphold PPSA services by securing a supply of free TB drugs via the public sector through the district TB team. These select physicians were motivated by the observation that access to free TB drugs broadened their patient coverage, improved patient retention, bolstered their marketing, and demonstrated sincere care for disadvantaged patients.

However, irregular TB drug supply persisted due to the absence of a formal contract, resulting in ad hoc support based on individual priorities of district leadership and the availability of public health staff. Certain hospitals expanded services by reallocating their own resources to maintain drug supply and minimal adherence support. Essential PPSA services such as diagnostics, routine home-based follow-ups, and supervision remained lacking.

On the other hand, while looking at the patients who were initiated on treatment through the PPSA model, we found them navigating the health system without clear guidance. This resulted in frequent switching across providers, changes in the treatment regimen, and lengthened treatment duration. Several patients who were newly initiated on TB treatment post-PPSA had still anticipated free services. Due to a mismatch in expectations, these patients navigated both the public and private sectors, causing delays in accessing treatment and an increase in treatment costs. Patients who were part of hospitals and clinics that retained partial services also remained anxious about the continuity of free prescription refills. Inconsistent free services heightened confusion, prolonged treatment, and altered treatment plans.

Initiatives like PPSA in India appear as one step forward and two steps backward in TB control. Short-term engagement generates dissatisfaction among private providers due to disruption in administrative and logistical efforts as well as routine treatment practices. Abruptly stopping specific TB services or partial PPSA increases the risk of treatment disruptions for patients, generates confusion when navigating the healthcare system, and demands alterations to treatment regimens. Patients in these areas might have chosen more consistent public TB services over incomplete PPSA services. The inability to sustain PPSA raises the concern that any gains made in eradicating TB from India through the model may be erased with the private sector regressing to prior standards of care.

The PPSA model, designed to improve the quality of TB care in India, should not be regarded as a start-stop arrangement but a lasting, consistent, and mutually beneficial partnership (11). Reinforcing PPSA should minimize disruptions in service by establishing longer-term PPSA contracts and shortening the transition period between PPSA contracts. At a minimum, the following components must be integrated into existing PPSA programmes: (i) creating a supportive ecosystem between private providers and the public sector district TB team, including an uninterrupted supply chain for free TB drugs; and (ii) conducting capacity-building and training initiatives for providers to continue PPSA services, enabling them to manage TB care delivery independently.

Integrating sustainability in India’s private sector TB care can help achieve India’s goal of eliminating TB. However, to achieve the intended goals of PPSA, it is imperative to strengthen the model by integrating dimensions of longevity and consistency. This strategy yields mutual advantages for both public and private sectors engaged in TB care.

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