India suffers disproportionately from the burden of infectious diseases and it accounts for nearly half of India’s disease burden. In 2013, India had 881730 cases of malaria; and every three minutes, two people die of tuberculosis (TB). Many new disease outbreaks such as dengue, swine flu, chikungunya, bird flu have occurred in India over the past decade. Also, drug resistance is posing a great public health risk especially with reports of increased prevalence multidrug resistant and extensively drug resistant TB, malaria resistant to artemisinin-combination therapy and various antibiotic-resistant microbes.
In India, private medical practitioners are the first point of contact for seeking care and they play a major role in managing infectious diseases. The private health sector is diverse and comprises various types of providers ranging from unqualified informal care providers to highly specialized doctors. Diagnosis and treatment provided by private practitioners often does not conform to standards of care. In addition, they do not necessarily report to government authorities about certain notifiable diseases, which are of public health importance. Hence the potential of private practitioners in controlling communicable diseases remains untapped in India.
To address this concern, the Indian Government introduced Integrated Disease Surveillance Project (IDSP) in 2004, with an objective of early outbreak detection and timely response. Under IDSP, public and private sector providers, laboratories and hospitals are required to report diseases either diagnosed or treated by them. But, the private practitioner participation in IDSP has been rather poor. Hence our health data reflects the reports mainly from the government hospitals and health centres, missing out on a huge number of conditions being seen in the private sector. This is a serious limitation in our disease control efforts.
Take for example TB, a notifiable disease in India since 2012. I have been working in a south Indian district trying to involve the private practitioners in the national TB programme (NTP). The district is doing well in terms of performance indicators for government facilities set by NTP for detecting and curing TB cases. However, there are thousands of patients who obtain treatment from private practitioners. Sadly, these practitioners do not necessarily report the details of patients treated by them to the NTP. When private practitioners treated TB patients, they often do not ensure the timely follow-ups and treatment completion. In the district where I work, it is estimated that around 52% of TB patients are missed by the system, which essentially indicates that these people who become ill with TB, have either not sought care at all or died or were treated by private sector and hence “missed”. According to the WHO, health systems across the world “miss” about three million TB cases each year, depriving them of the care that they need. The unavailability of the information from the private sector makes it extremely difficult for the NTP managers to formulate appropriate public health strategies.
So, what is the way out? Behavior of private practitioners critically depends on the regulatory environment and also to some extent on the functioning of public health sector and local demands. Ways must be found to influence the behavior of private practitioners in favor of public health. Two possible strategies could be “Regulation” and/or “Collaboration”. Both approaches have strengths and weaknesses. Health sector regulation is rather weak in India. On one hand, there is no registry of private medical practitioners, while on the other most national health programmes neglect the private health sector. A legal framework is also weak; only few states in India are implementing laws such as the Clinical Establishment Act to regulate the private sector, which makes it mandatory for private sector to register with district health authority. If we consider collaboration as an approach, there are major structural and attitudinal impediments to public-private collaboration and there is a need to build trusting relationships between government, professional organizations and private practitioners to make this collaboration work.
Given the significant proportion of patients seen in private sector and the varied management practices, involving private practitioners in national programmes can no longer be overlooked. A mixed health system such as India cannot but engage in one way or another with the private sector. How much of “regulation” and how much of “collaboration” ought to depend on safeguarding public health concerns.