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Regulate or collaborate? The puzzle of private medical practitioner’s engagement in disease surveillance in India

By on June 3, 2015

Vijayashree is working as faculty at Institute of Public Health, Bangalore, India. She is also pursuing her PhD at the Institute of Tropical Medicine, Antwerp. For her PhD, she is carrying out an implementation research to involve private practitioners in National TB Programme. Her main research interests are in regulating private health sector and disease control programmes. 

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.

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7 Responses to “Regulate or collaborate? The puzzle of private medical practitioner’s engagement in disease surveillance in India”

  1. Mahesh

    Thought provoking blog which flags state of dilemma that exists in public health delivery system in India. Collaboration is the need of hour where we r moving away from regulatory framework.

    Reply
  2. Dr Ramesh S Patil MBBS RMO Sambhram Hopsital KGF

    The laws about notifiable disease are there but as it happens with such Good ” laws they are so easily ignored.I personally could not agree more with a campaign for Notifiability-making it some sort of an offence if not followed by concerned practitioner.My personal experience is (not here in Karnataka) whenever reported to PHC-the receiving end is/was not also very particular and committed as much you seem to be yourself.So awareness has to be on both side.One intriguing problem about GPs is these days it is almost overtaken by Non allophonic Doctors-who boldly venture into treating the diseases themselves you have mentioned.How r we going to tackle this problem.I do not mean that is your problem nevertheless it becomes one of yours for the simple reason of the enormity of the issue you propose to tackle.Govt should send the list of all the communicable/notifiable diseases to all PP of all specialities- mentioning that it would be considered a breach of this law to to treat such patients without the notice of concerned authority.Dear madam I wish you Good luck (you need it indeed)in the pursuit of this undertaking while I assure on my part to cooperate with my -squirrel’s part.

    Reply
  3. Dr G D Raghavan, District T b control Officer, Davanagere, Karnataka

    Good one. But still, the contribution from private sectors towards implementation of National programmes is not so satisfactory. Now since the enforcement of KPME act since 2011, we can look forward for the active involvement of private establishments. As far as RNTCP is concerned, it is sub optimal in many districts.
    Expecting more interesting blogs…..

    Reply
  4. Dr. Almas Shamim, MSF- Access Campaign (India)

    The article aptly spells out the problematic nature of the mistrust that exists between India’s public and private sectors. Indeed, both regulation and collaboration are required if desired results have to be obtained. And I dare say, sometimes, the need would be of a ‘regulated collaboration’ as is shown by the poor uptake of the ‘notification’ of tuberculosis by the private sector. In my short stint with RNTCP, I have personally visited some major private practitioners in my place informing them of the need for notification, yet, there had not been much response.
    I wonder if there is a feeling of losing patients (and the accompanying money) if cases are notified. It would be interesting to know (if the author could shed some light on it based on her work in this field). The absence of any consequences is, obviously, a major contributor to the indifference shown.
    While we are talking about notification, it would also be of importance to assess the Govt.’s capacity to, then, take care of the cases notified (from the private sector)- provide them good quality diagnostics, C-DST, drugs and help ease their OOP expenditure. We have a long way ahead of us.

    Reply
  5. Petros Isaakidis

    We contacted a mixed-methods study among private practitioners in Kerala and our results were interesting, “paradoxical” and we hope helpful. The link to the PLoS One publication:
    http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0123286

    Reply
  6. DrGurram Krishnamurthy Sanathkumar

    Government of Karnataka has done remarkable achievement by bringing KPME act to register and control private hospitals, but unfortunately they are concentrating only registering and not supervising these hospitals, it has got more powers to control private hospitals and they should strictly instruct all diseases should be notified if they are not abide by these rules such establishments should closed down. This article will put some light on private practioners to understand the importance of not notifying.

    Reply
  7. Modi-fying India’s health: Health in the times of India’s new prime minister | daktre.com

    […] take, how much of collaboration and how much of regulation is still to be seen (see for instance Vijayashree Yellappa’s reflection on this). Whether invited or not to the healthcare party, the private sector is here to stay. If indeed […]

    Reply

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