Ibrt07i2p79

Indian Journal of Tuberculosis
79
PUBLIC-PRIVATE MIX TB ACTIVITIES IN MEERUT, UTTAR PRADESH, NORTH
INDIA: DELIVERING DOTS VIA COLLABORATION WITH PRIVATE PROVIDERS
AND NON-GOVERNMENTAL ORGANIZATIONS
Shruti Sehgal1
, Puneet K Dewan2
, L. S. Chauhan3
, Suvanand Sahu1
, FraserWares1
and Reuben Granich4
1 Office of the World Health Organization Representative to India, New Delhi, India
2 Division of TB Elimination, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
3 Central Tuberculosis Division, Directorate General of Health Services, Ministry of Health and Family Welfare, New Delhi, India
4 Office of the US Global AIDS Coordinator, Pennsylvania Avenue, Washington DC
Correspondence: Dr. Shruti Sehgal, WHO RNTCP Medical Consultant, 529 ‘C’Wing, Central TB Division, Directorate General of Health Services,
Ministry of Health & Family Welfare, New Delhi-1100011; Email id- sehgals@tbcindia.org; Mobile-9810221855;
Fax-011-23063226
Summary:
Background: We evaluated the contribution of public-private collaboration between the Indian tuberculosis (TB) programme
and the private health sector (including non-governmental organizations and private providers) to TB case-detection and
treatment outcomes in Meerut district, India.
Methodology: District TB registers from January 2001-June 2003 were reviewed.
Results: The 2002 new AFB-positive case-notification rate (103/100,000 population) in Meerut exceeded national
targets. Of the 7,062 new AFB-positive patients registered, 2,084 (29%) were detected at private sector microscopy and
DOTS treatment centres; treatment outcomes met programme targets.
Conclusion: Public-private collaborations can be successfully implemented at the district level in India, and have the
potential for substantial contributions to TB control efforts in India.
Key words: Tuberculosis, Public-Private Mix, DOTS, RNTCP, NGOs
(Original version received on 22.8.2006. Revised version received on 16.3.2007. Accepted on 20.3.2007)
INTRODUCTION
In 2004, an estimated 1.8 million new TB
cases and around 330,000 TB-related deaths
occurred in India, representing one-fifth of the global
burden of incident TB cases and mortality1
. The
Indian Revised National TB Control Programme
(RNTCP) began large-scale nationwide
implementation of the WHO global TB control
strategy (DOTS) in 1998, and rapidly expanded to
cover the whole country by March 2006. In 2005,
almost 1.3 million TB patients were registered for
treatment under RNTCP, with the new smear positive
pulmonary TB case detection, standing at 66%,
almost reaching the global target of 70%2
. Treatment
success of such cases, at 86% (2004 cohort),
achieved the 85% global target.
However, almost half of TB patients in India
may seek care initially in the private health care
sectors, where diagnostic, treatment, and reporting
practices often do not meet national or international
standards for TB3-5
. Subsequent diagnostic delays
and inadequate treatment may result in extended
infectiousness, acquired drug resistance, treatment
failure, and high rates of relapse – all of which may
impair Indian TB control efforts.
Collaborations between the public and
private health sectors, or public-private mix TB
activities (PPM TB), may be an important solution.
After early experiences showed the potential value
of PPM activities6-8
, the RNTCP developed formal
guidelines to help local programmes structure
collaborations with private health providers and
NGOs9,10
. These guidelines offered a diverse group
of plans for the diverse community of private
providers and NGOs, with options to participate in
the referral, diagnosis, and/or treatment of TB
patients.
OriginalArticle
[Indian J Tuberc 2007; 54:79-83]

80
Here we describe the effect of PPM TB
collaborative activities on TB case notification and
treatment outcomes in one district of north India.
METHODS
Meerut district, in the north Indian state of
Uttar Pradesh, population 3 million, started RNTCP
in July 2000. Many persons in Meerut access medical
care through private providers, even though public
healthcare facilities are available. With a view to
increase the access of such patients to the quality
TB services under RNTCP, the district TB
programme began to involve charitable NGO’s and
SHRUTI SEHGAL ET AL
Table 1: Case detection by sector, Meerut district, January 2001 – June 2003
Sector
Cat I
NSP
%
Cat I
Other
% Cat II % Cat III % Total %
Public 5122 71 161 61 1547 69 4232 73 11062 71
NGO 1617 22 55 21 563 25 1067 19 3302 21
Private 467 7 49 19 140 6 484 8 1140 7
Total 7206 265 2250 5783 15504
71
61
69
73
22
21
25
19
7
19
6
8
0 10 20 30 40 50 60 70 80
Cat I NSP %
Cat I Others %
Cat II %
Cat III %
Privat
NGO
Publi
Case Detection by sector , Meerut district, Jan 01- June 03
RNTCP Revised National TB Control Programme
NGO Non governmental organization
Cat I NSP New patients with sputum-smear results positive for acid-fast bacilli (AFB-
positive)
Cat I Other Seriously ill patients (AFB-negative or extra-pulmonary)
Cat II Pulmonary or extra-pulmonary TB Patients receiving re-treatment regimen
Cat III New AFB-negative or new extra-pulmonary patients

81
private hospitals in the diagnosis and treatment of
TB patients under RNTCP through local initiatives.
The first NGO to become involved was
Falah-e-Am, a non-profit faith-based organization
cateringtoalarge,predominantlyMuslimshantytown
with an estimated population of between 350,000–
650,000. Over the subsequent 18 months, the
programme opened additional microscopy and
treatment centres in 3 more NGO’s and 4 private
hospitals, including 1 in a private medical college.
In a given collaboration, the private or NGO
health facility provided the facilities and staff to run
the respective microscopy or DOTS treatment centre.
The programme provided training for the laboratory
technicians and treatment providers, a binocular
microscope to NGO / private facilities and supplies
for microscopy activities to all those facilities that
were designated as an RNTCP microscopy centre,
and anti-TB drugs for all registered TB patients.
Supervision was conducted via bi-weekly visits by
programme staff. The private or NGO medical facility
staff performed treatment, and in some instances
stocked RNTCP drugs to facilitate early initiation of
anti-TB treatment. RNTCP staff was available to
assist in the retrieval of patients who interrupted TB
treatment or were delayed for their follow –up
sputum for more than a week.Afixed annual stipend
of Rs 50,000, approved by the RNTCP, was paid to
two of the collaborating NGO medical facilities to
help defray the costs of collaboration.
A retrospective review was undertaken
using data collected from the RNTCP TB registers
and aggregate monthly laboratory reports. The total
PPM ACTIVITIES FOR TB CONTROL IN NORTH INDIA
Table 2: Treatment outcomes among new smearAFB-positive patients by health sector, Meerut
district, January 2001 – June 2002
Public NGO* Private
Treatment Outcome No. % No. % No. %
Cured 2936 93 979 94 149 96
Completed Treatment 13 0 4 0 0 0
Death 88 3 26 3 5 3
Failure 10 0 1 0 0 0
Default 123 4 30 3 1 1
Transfer Out 02 0 0 0 0 0
Total 3172 1040 155
* p-value not significant for Chi- square (χ2)
test of the null hypothesis of equivalent distribution
across the cohorts
Cured Initially sputum smear – positive patient who has completed treatment and had
negative sputum smears, on two occasions, one of which was at the end of
treatment
Completed Completed treatment, smear AFB negative at the end of the intensive phase but
without end of treatment sputum smear evaluation
Failure Smear AFB-positive at 5 months or more after starting treatment
Death All cause death during TB treatment
Default Interrupted treatment >2 months
Transfer out A patient who has been transferred to another Tuberculosis Unit / District and
his/her treatment result (outcome) is not known.

82
number of patients examined for diagnostic smear-
microscopy and the number with acid-fast bacilli
(AFB) positive results were recorded, and cross
checked with laboratory registers. Treatment
outcomes for new AFB-positive patients were
abstracted from the TB registers. An NGO medical
facility was defined as a medical facility operated
by a non-governmental society registered under the
Indian Societies Act. Private medical facilities
included privately owned hospitals, medical colleges,
or corporate hospitals. A private or NGO case
detection was defined as a registered TB patient
whose treatment was initiated at a microscopy and
DOTS treatment centre managed by a private or
NGO health facility. All data were analyzed with
Epi-Info 6.04d (CDC, Atlanta, USA). A p-value of
=0.05 was considered significant.
RESULTS
Of the 25 microscopy centres functioning
in June 2003, the public sector operated 18 (72%),
NGO’s 4 (16%), and private health facilities 3 (12%).
From January 2001 to June 2003, 58,645 TB
suspects were examined by sputum smear
microscopy. Of these, 14,657 (25%) were examined
at an NGO or private microscopy centre. Private
and NGO facilities detected 2,084 (29%) of the 7,062
newAFB-positive patients diagnosed and registered
under RNTCP (Table 1). One NGO (Falah-e-Am)
contributed 17% of the new AFB-positive cases
registered, the largest such contribution from any
single health facility in the district. In 2002, the
reported case notification of Meerut district of 103
new AFB-positive cases per 100,000 population,
corresponded to 108% of the estimated caseload 11,12
.
Treatment outcomes were available for
4,367 new-AFB positive patients registered from
January 2001 to June 2002 (Table 2). Treatment
outcomes did not differ between patients treated by
NGO or private hospital DOT providers compared
to public sector DOT providers (p=0.5).
DISCUSSION
The experience of RNTCP in Meerut district
serves as an example of local programmatic
implementation of PPM TB collaboration. After
involvement of the NGO and private sector in RNTCP
activities, the case notification in 2002 (103 per
100,000 population) exceeded both the RNTCP target
and the estimated incidence of 95 per 100,000
population 11,12
.
Nearly one-third of all patients reported
under the RNTCP in Meerut were detected and treated
through public-private collaborations, including 29%
of new AFB-positive patients. Public-private
collaboration project evaluations in other cities of
India (Hyderabad, Mumbai and New Delhi) have
found similar contributions to TB case detection6,7,13
.
Treatment outcomes for patients treated by
DOT providers in the NGO or private health facilities
were equivalent to those of the public sector DOT
providers. This is in contrast to the findings in other
countries, where DOT provision by private
practitioners, in the absence of TB programme
supervision, has been associated with poor treatment
outcomes14
. In Meerut, as in other RNTCP initiated
PPM TB initiatives, the public sector programme staff
provided ongoing supervision of the private and NGO
DOT-providers, and this may have played a role in
ensuring the similar treatment outcomes amongst the
different sectors that were seen.
One limitation of this retrospective
evaluation was the reliance on the pre-existing data
in the TB registers and RNTCP surveillance reports.
We may have underestimated the private sector
contribution to case detection, as patients diagnosed
by a private provider but referred to a public sector
facility for treatment, would have been misclassified
as a “public sector case detection”. Also as the PPM
TB collaboration began almost simultaneous to the
implementation of RNTCP in the district, we were
unabletoquantifytheadditionalcasedetectionyielded
through the PPM TB collaboration. However the
overall impact is likely to have been positive.
CONCLUSIONS
Nearly one-third of TB cases in Meerut were
detected and treated through the collaboration
between the public sector and the NGO or private
SHRUTI SEHGAL ET AL

83PPM ACTIVITIES FOR TB CONTROL IN NORTH INDIA
sector providers. Overall district case detection
exceeded national targets, and treatment outcomes
remained above 85%. Public-private mix in TB
control can be successfully implemented at the
district level in India, though collaboration
sustainability remains to be demonstrated.
ACKNOWLEDGEMENTS
We wish to acknowledge the assistance of
the public sector, WHO, and collaborating NGO and
private medical facility staff, without whom this
evaluation would not have been possible. These
included Dr VK Bakshi, District TB Officer, Meerut,
and the district programme staff, Mr Deepak Gupta,
former Joint Secretary, Ministry of Health and Family
Welfare, Drs Y Mundade and YN Prabhakar,
RNTCP-WHO Medical Consultants, Dr SS Lal,
WHO India (NPO, PPM-TB) and Dr P Srikantiah,
University of California, San Francisco.
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3. Prasad R, Nautiyal RG, Mukherji PK, Jain A, Singh K,
Ahuja RC. Treatment of new pulmonary tuberculosis
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11. Chadha VK, Vaidyanathan PS, Jagannatha PS,
Unnikrishnan KP, Mini PA. Annual risk of tuberculous
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www.tbcindia.org/TB2003-Part1.pdf
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Dr. S.P.Agarwal, President, TuberculosisAssociation of India, was conferred
Doctorateof Science(honoriscausa)inthe56thAnnualConvocationofPanjabUniversity
heldon7thMarch,2007intheGymnasiumHallontheUniversityCampus. HisExcellency,
Dr.A.P.J.Abdul Kalam, President of India, delivered the convocation address.

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