Planning a Role for Private Practitioners in TB Control: Obstacles & Opportunities

Despite much worldwide attention and implementation of the WHO recommended DOTS strategy by 119 countries, only 40% of estimated tuberculosis cases are notified worldwide. Experts believe that private practitioners manage a large proportion of the unreported majority of tuberculosis cases. A large proportion of tuberculosis patients in high prevalence countries such as India, Pakistan, Philippines, Vietnam, and Uganda first approach a private practitioner. For example, a household survey in India found that 60% individuals with a longstanding cough first went to a private practitioner. Another study noted that 88% of rural and 85% of urban patients with tuberculosis first went to a private practitioner. Tuberculosis management practices of private practitioners have recently come under scrutiny worldwide. (Private practitioners and public health: weak links in tuberculosis control: Mukund Uplekar, Vikram Pathania, Mario Raviglione, Lancet 2001; 358: 912-916 )

With this background in mind, Health and Development Initiative-India conducted personal interviews with 25 private practitioners of Amritsar District (population 3.2 million) of Punjab State of India, who treat patients of Tuberculosis on regular basis. The objectives of these interviews were to assess the load of TB patients in their practice settings, determine their current level of involvement with National TB Control Program (NTP) and explore the avenues of possible communication and collaboration with them.

Questions and answers follow.

How many fresh cases of Pulmonary Tuberculosis do you get on an average in a month?

• Less than 5: 64%
• Between 5-10: 36%

What initial investigation do you actually order in a patient with cough for the last three weeks or more?

• X-ray Chest: 80%
• Sputum examination for AFB: 12%
• ESR: 8%

When were you last contacted by officials from Government Health and Family Welfare Department to inform you about National TB Control Programme (NTP) guidelines?

• Never contacted till date: 100%

When did you last participate in a Continued Medical Education Program on TB treatment or control?

• I do not remember having participated in such a CME programme: 64%
• I attended a CME on TB about 1-5 years ago: 16%
• I attended a CME on TB in the last 12 months: 20%

Who organised this CME?:

• Professional organisation: 66%
• Pharmaceutical Company: 34%

If the NTP were to provide you with free anti-TB drugs what would you do?

• I will pass on free anti-TB drugs to my patients without any service fee: 72%
• I will pass on free anti-TB drugs to my patients with some service fee: 24%
• I will decline the drug supply: 4%

Do you maintain a record of TB patients under your treatment?

• No: 80%
• Yes: 20%

Do you have a facility to trace a defaulting patient receiving TB treatment from your clinic?

• No: 100%

How can you be best reached to provide you information about NTP?

• By postal mail: 64%
• Personal Contact: 20%
• E mail: 1

1. Private practitioners (PPs) get a large number of fresh cases with PTB. 36% PPs diagnose as many as 5 to 10 fresh cases every month.

2.The awareness of these PPs is awfully low about NTP guidelines. It is much worse than their colleagues in public health system. Only 12% actually ask of Sputum examination for AFB in patient with cough lasting for three or more weeks.

3. The public health system seems to have consciously chosen to keep PPs out of the purview of NTP. All the respondents had never been contacted by NTP managers to inform about its guidelines.

4.The opportunities for PPs to acquire knowledge about latest in TB control and management do not exist in the field. 64% of those interviewed never had an occasion to participate in a CME program on TB control. Only 20% participated in such a programme in the last 12 months. One third of these meetings were organised by pharmaceutical houses.

5. A large number of PPs (96%) are prepared to participate and collaborate with NTP. When asked as to what would they do if NTP decides to provide free anti-TB drugs for their patients, 72% offered to pass on these drugs to their patients without any service charges and 24% said they would charge a nominal fee to meet their expenses. Only 4% said that they would decline the drug supply.

6. There are evident problems in entrusting management of TB patients to PPs. 80% of them do not maintain any record of patients under their treatment and all of them do not have any system to trace a defaulting patient. When further probed some of them said they were ready to maintain records but could not suggest any satisfactory means to trace defaulters, consistent with programme requirements.

7. 64% of those interviewed said that they would like to receive information about NTP by ordinary mail. Only 16% of them have access to internet and preferred information via internet/ e-mail.

To summarise, the study indicates that PPs are getting a significant number of fresh PTB cases and these are not being reported to NTP. The opportunities for them to acquire information about NTP guidelines hardly exist in the field and some of these are pharmaceutical industry driven. Most PPs are willing to cooperate with NTP but there are obvious problems in this regard. Most PPs wish to receive information about NTP guidelines by post.

The managers of NTP will have to come out with effective communication strategies. A beginning could be made by making available a written document on the lines of CDCs Core Curriculum on TB.

For more information, contact:

Dr. Dinesh Kumar

Director

Health and Development Initiative-India

73-FF MIG Flats

B-Block Ranjit Avenue Amritsar_143001

India

dkumar1@sancharnet.in