Rajasthan chief minister Ashok Gehlot. Photo: PTI.
Jaipur: Based on the NITI Aayog’s recommendation that the private sector’s engagement is important to achieve universal access to tuberculosis (TB) care, the National Strategic Plan for Tuberculosis Elimination 2017-2025, drafted by the Narendra Modi government, includes private TB providers.
In this system, the government gives TB patients approaching private clinics free drugs, diagnostics and incentives. In many places, this is done through a private agency that ensures free drugs reach registered providers, takes patients’ microbiological samples collected at the clinics to government labs, shares test reports and finally counsels patients until treatment is over.
This ‘patient provider support agency’ (PPSA) model is part of the ‘Joint Effort for Elimination of TB’ (JEET), and is operational in 50 districts around India.
For each patient, the government also provides private treatment facilities an incentive of Rs 1,000 in two instalments, Rs 500 to notify the patient on an online government portal called Nikshay, and another Rs 500 to report treatment outcomes.
JEET is usually available only in a few districts in every state – so most districts undertake the private engagement mandate through a public officer. This is the district PPM coordinator.
As a result of such engagement, the government has reported a remarkable surge TB notifications. According to a recent report, over 70% of people showing TB symptoms have approached private sector facilities as the first point of care.
However, despite this fairly good show, the Rajasthan government has decided to eliminate contract agency services.
“It was felt that we need to slightly modify the private sector engagement model in Rajasthan,” state TB officer Vinod Garg told The Wire. However, he didn’t say how the government plans to make do without the private agency model.
In Rajasthan, JEET is operational in seven of 33 districts: Jaipur, Sikar, Bikaner, Udaipur, Jodhpur, Ajmer and Kota. In 16 other districts – Nagaur, Tonk, Chittorgarh, Bundi, Sri Ganganagar, Baran, Bhilwara, Banswara, Rajsamand, Alwar, Bharatpur, Dholpur, Sirohi, Jalore, Churu and Jhunjhunu – a simpler version of JEET, called the PPSA-lite model, is at work. In this variant, an agent in the district sensitises private-facility doctors about notifying patients, stocking TB medicines and managing free tests at government facilities.
And in the remaining ten districts, the government has created the post of PPM coordinator to facilitate private engagement – and this post has been vacant in many districts. It’s possible that the Rajasthan government will bank on these coordinators after scrapping the PPSA model to ensure the private sector fulfils its obligations.
This is where the problem lies. The Rajasthan government has had an abysmal record of disbursing incentives to private sector providers.
An RTI application that The Wire filed revealed private TB providers in ten districts haven’t received monetary support from the government since August 1, 2019. These are Barmer (83 registered private providers), Chittorgarh (53), Dholpur (94), Dungarpur (22), Jaisalmer (26), Jhunjhunu (116), Nagaur (72), Pratapgarh (7), Rajsamand (41) and Tonk (58).
As it happens, these districts also lack contract agency services or use the PPSA-lite model.
So in these areas the government is managing private sector engagement using its own resources – and doing a terrible job of it.
And in total, private TB providers in these ten districts have notified 4,328 TB patients between August 1, 2019, and September 11, 2020 – but haven’t received any of the promised incentives.
“The incentive of Rs 500 makes no difference in our earnings,” Krishna Kumar Singhal, a private TB provider in Jaisalmer, told The Wire. “But it consumes our time and energy in unnecessary paperwork.”
According to Singhal and others in his position, when they notify a patient on the Nikshay portal, they need to keep adding her treatment details until the treatment regimen is complete.
If a notified patient refuses or neglects to continue treatment – which is quite common – a pendency arises in the record, imposing more bureaucratic hassles on private providers.
Dhanesh Soni, who manages a contract service in Pratapgarh, said local state authorities had invited him for a dialogue during a meeting – with nothing happening after. “The condition is such that we don’t know even if there is any sort of private engagement happening here,” Soni said.
A doctor from the Golden City Hospital, Jaisalmer, said the government’s promise of free medicines is also seldom fulfilled.
As a result, experts are not confident about the feasibility of the government’s new plan, to jettison the PPSA model.
“Establishing an agency has a massive cost involved,” said Shamim Mannan, of the Clinton Health Access Initiative. “Since states are free to implement the allotted TB budget the way they wish, we are also looking at how Rajasthan will handle the whole system.”
As it happens, private providers in other states that have been implementing successful PPSA models, and continue to do so, are also having a tough time getting money from their governments.
“We haven’t received the budget for carrying on the PPSA services for quite some time now. I’m afraid if things will continue this way, we might have to shut down,” Nita Jha, project director at World Health Partners, which has been working in Bihar for the last decade, told The Wire.
In 2019 and 2020, several high TB burden states have diverted significant portions of their health budgets towards PPSA services. But now, states are either delaying allocations or are simply scrapping the PPSA system.
Shruti Jain is a Survivors Against TB Media Fellow. This story was covered as part of the Survivors Against TB Media Fellowship 2020, awarded to encourage evidence-based, empathetic reportage on important issues related to TB.