tb in india-role of private sector-amit sengupta phm

7/28/2019 TB in India-Role of Private sector-Amit Sengupta PHM

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Tuberculosis in India

Health System issues and the role ofthe Private Sector

Amit Sengupta

Peoples Health Movement, India


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Development of Health Care Services

Since early 1990s in consonance with overalleconomic policies withdrawal of the state from the

social sector became part of public policy

Huge cuts in health budgets in 1993 & 1994, followedby some restoration

Expenditure as percent of GDP fell from 1.4% to 0.9% Led to a virtual dismantling of public services

Public outcry led to the Govt. promising remedialmeasures in 2004 and in setting in motion the National

Rural Health Mission in 2005.

The NRHM has strengthened public services in someareas, but access still extremely inadequate


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State of Public Health Systems

Growth of infrastructure has lagged behind

demand.

Creation of new infrastructure has lagged wellbehind targets

Achievement of targets is 76% in the case of sub-centres but just 13% and 37% in the case of PHCsand CHCs.

Even where sub-centres, PHCs and CHCs exist,their conditions are often poor -- 50% ofsub-centres, 24% of PHCs and 16% of CHCsfunction in rented or temporary premises


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Source

Location(percent)

Income Quintile(percent)

Total

Urban

Rural Lowest Second Middle Fourth Highest

Publicsector

29.6 36.8 39.4 37.1 39.0 33.9 22.6 34.4

NGO or trusthospital

0.5 0.3 0.3 0.3 0.3 0.5 0.5 0.4

Privatesector

69.5 62.5 59.9 62.2 60.4 65.3 76.4 64.8

Othersource

0.2 0.2 0.2 0.2 0.2 0.2 0.2 0.2

Source of Health Care


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State of Public Sector encouragesGrowth of Private Sector

State of the public health system forces people toaccess the unregulated private sector

As a consequence in excess of 80% of medical carecosts are borne by people through out of pocketexpenses

Survey shows that, in the case of ailmentsconsidered serious by respondents, 40 percentcited financial reasons for not taking recourseto treatment


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Structure of Private Sector in India

Primary: Individual practitioners -- qualified andunqualified -- provide outpatient care and located in

both rural and urban areas.

Secondary level of care provided by nursing homeswith a bed strength ranging from 5 to 50

Further division between small and large nursinghomes -- differ widely in terms of investments,equipment and facilities, range of services offeredand quality of care.

Tertiary level: multi-specialty hospitals -- mostlylocated in the larger cities with a strong Non ResidentIndian (NRI) connection with doctors based in the

United States and with corporate entities


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Health Care Expenditure

India spends around 5.2 percent of GDP on health --

higher than countries with comparable per capitaincome or even better off countries

At 4.2 percent of GDP, Indias private expenditure isamong the top twenty countries in the world

Public expenditure (0.9 percent of GDP) is amongthe bottom five in the world

Households (out of pocket) 69%Government (Central, State and local) 26%International funds 2%Private-not-for-profit 3%


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Health Care Expenditure.. Contd..

60% of expenditure goes on primary care services,85% (almost 50% of total spending) for primary

curative care services

Government expenditures account for 24% ofinpatient treatment

Although fees in government hospitals are low,households still report sizable out-of-pocketexpenditures on drugs and supplies for hospitalizedpatients

Estimated that private health expenditure has grownat 12.5% per annum, since 1960-61

The income elasticity is 1.47, which means that foreach 1% increase in per capita income, the

private expenditure on health increased by 1.47%


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Public Private Partnerships

Endorsement by multilateral agencies of PPPs has

influenced policy

At the secondary level, PPPs are involved in contracting out ofnon-clinical services like laundry,

diet, drug stores, diagnostics, ambulance

Selective contracting out of services to the privatesector is often a component of reform packagespromoted by bilateral and multilateral agencies for

low- and middle-income countries

PPPs now also extend to contracting out clinicalservices


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Privatisation: Panacea or Problem?

Common argument promoting increased private

provision of health services is that it can bring indesperately needed additional capital and capacity inlow-income countries.

But Private sector provisioning of health care require

huge public subsidies to thrive -- cash subsidies,subsidized medical education, subsidized or freeinfrastructure (land, etc.) and tax breaks

Private sector also competes to provide care in

urban centres, and not in underserved areas i.e. itdoes not complement public services but competes

Competes also by drawing away human andtechnical resources away from public sector


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Access to Medicines

Estimated by different sources -- 50% to 80% not able

to access all the medicines they need The World Medicine Report (2004) of WHO - India has

largest number of people (649 million) without accessto essential medicines

Given India is the 3rd largest producer of drugs in theworld and exports medicines to over 200 countries,local production/availability not major constraints.

Studies indicate that poorer populations spend a largerproportion of health care expenditure on medicines.

World Bank Study: out-of-pocket medical costs alonemay push 2.2% of the population below the povertyline in one year


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Health Exp.(Rs.)

Exp. onMedicine (Rs.)

Medicine %Health

Quintiles Rural Urban Rural Urban Rural UrbanFirst

(Lowest) 7.72 11.71 6.68 9.91 86.47 84.60

Second 13.79 21.66 11.71 17.49 84.89 80.71

Third 19.61 29.73 16.46 22.72 83.94 76.44

Fourth 29.98 47.00 24.44 34.34 81.53 73.05

Fifth 77.47 105.67 55.46 65.90 71.59 62.36

Total 29.58 43.27 22.85 30.14 77.24 69.66

Pattern of Out of Pocket Expenses on

Medicine andHealth Care


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Access to Medicines .. Contd..

Estimated that total expenditure on medicines in

India is in excess ofRs.600 billion per annum --Rs.3,000 for every family in the country

Factors that determine access to medicines include:

rational selection and use affordable prices sustainable financing responsive health system reliable supply system

While affordability is only one dimension of access, itcontinues to be a critical factor in Indias Healthsystem


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Special Features of Indian Pharmaceutical Market Most prominent: very large proportion of drugs

consumed in India are through retail sales (85%)

Institutional sales include public sector and privatehospitals and other institutions.

Pattern different from most markets, where a bulkof drug consumption is through supplies from largeinstitutional mechanisms (hospitals, healthinsurance, etc., both in public and private sector).

Given this, major issues related to drug prices arerelated to those that impact on retail prices


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DPCOYear Drugsunder

PriceControl

% of Marketin Price

ControlledCategory

Mark-up (profitability)

allowed

1979 347 80-90% 40%, 50% and 100% in threecategories termed life

saving, essential and nonessential

1987 142 60-70% 75% and 100% in twocategories, subsequently one

category with 100% mark up1995 74 25-30% 100%2013

343

20-20%

Market based price fixation

Dilution of Price Controls in Successive Policies


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TB treatmentin the private sector

in the context ofIndias Health System


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TB is not just a Disease, it is a Public Health issue

While medicines are important for TB treatment, its

effective control depends on a range of public healthmeasures and measures that address the broaderdeterminants

TB is also a social issue with continuing stigma

attached to it Treatment of TB is crucially dependant on a

functioning health system and other social protectionmeasures


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Medicines play a limited role in TB control.


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TB Treatment in the Public Sector

DOTS is claimed to have been a game changer

In 2000, the prevalence rate of TB in India was 338 per100,000 population and the mortality due to TB was 42per 100,000 population.

In comparison, in 2009, the prevalence of TB in Indiawas 249 per 100,000 population and the mortality dueto TB was 23 per 100,000 population


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However several questions remain

How much of the success of DOTS is related to

introduction of new drugs from the old 18 monthregimen of Streptomycin, INH, Thiocetazone and PAS?

Studies have shown a very high incidence ofinappropriate care and rejection of patients on the

basis of their being 'non-ideal' candidates, who willspoil the statistics

People without permanent addresses and migrants

may not be enrolled under DOTS despite theirdefinitely needing care

Emergence of MDR TB puts into question the

sustainability of the present model


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TB Patients fall through the cracks in the PublicSystem..

A study conducted in a hospital setting among TBpatients, not exposed to TB services offered in thepublic sector, found 170 out of 200 patientsinterviewed (85%) to be unaware of the DOTSprogramme.

5080% of TB patients in India still seek care atprivate clinics

Out of the total market of USD 94 million for the first-

line anti-TB medicines in India (2009), the publicsector purchases drugs worth USD 24 million whilethe private sector accounts for the remaining USD 61million


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Hearing from the unheard ..

Tokavda PHC, Taluka Murbad, Dist. Thane

Soni Shiva Wagh, age 45 years, was suffering from low grade fever and

weakness for 3-4 months and went to the PHC for treatment.

She was given some medicine but got no relief, so she went to a privatedoctor who diagnosed her as having T.B. and directed her back to thePHC as she could not afford to buy the drugs required

The PHC doctor sent her back with medicines for Malaria.She then went to the Govt. Hospital in Murbad and told the doctor thatshe had been diagnosed for T.B. Since the X-ray machine was notfunctional she was asked to get a chest X-ray done in a private X-raycentre.

After 4 days when she went back to the hospital for sputum examinationthe technician was unavailable. She was asked to return to the hospital onthree consecutive days for the tests which were ultimately never done.


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Amethi- Sultanpur district, UP

Triveni Prasad Gupta, went to district hospital where he was diagnosedas suffering from TB. The treatment continued for the same without

any reliefand he had to buy the medicines from the market .

With no respite he finally got tests done at a private nursing home andwas diagnosed to be HIV positive and referred to KGMU Lucknow.

In KGMU was asked to go back and take rest .

On much persuasion the doctors agreed that he get testedaftersamples were drawn told to come back after a week.

He again went back to the district hospital and was asked to getconfirmatory rests done in a private nursing home

The family had spent nearly 20 000 rupees on medicines and tests bythis time.

He died before being put on treatment for both HIV and TB


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Nahan District, Himachal Pradesh

Ashwini Kumar was put on anti-Tuberculosis treatment for

the first time in 1976

Since then he has undergone a full course of ATTmedication 9 times at the PHC, TB Sanatorium and Districthospital.

Finally in May 2004 he was referred to I.G.M.C Shimlawhere he was made to undergo tests costing Rs. 30,000.

At this stage his lungs were completely damaged and heexpired after a few weeks (in 2004)


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How is TB Treated in the Private Sector?

1991 study of prescribing behaviour of privatepractitioners in Mumbai : 100 doctors provided 80

different prescriptions

1998 study in Mumbai and rural Pune: 105 privatepractitioners provided 79 diverse prescriptions

2009 study ofpractitioners in Dharavi, Mumbai: only 6of the 106 wrote a prescription with a correct drugregimen and they wrote 63 different prescriptions --there were no significant differences between theprescriptions offered by doctors trained in Westernmedicine and those trained in alternative systems

Udwadia ZF, Pinto LM, Uplekar MW (2010) Tuberculosis Management by Private Practitioners in Mumbai, India: HasAnything Changed in Two Decades? PLoS ONE 5(8): e12023. doi:10.1371/journal.pone.0012023


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Analysis of the physicians' prescriptions for MDR TB


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Analysis of the physicians prescriptions for MDR TB

Udwadia ZF, Pinto LM, Uplekar MW (2010) Tuberculosis Management by Private Practitioners in Mumbai, India: Has

Anything Changed in Two Decades?. PLoS ONE 5(8): e12023. doi:10.1371/journal.pone.0012023http://www.plosone.org/article/info:doi/10.1371/journal.pone.0012023

Market promotes irrational treatment
http://www.plosone.org/article/info:doi/10.1371/journal.pone.0012023http://www.plosone.org/article/info:doi/10.1371/journal.pone.0012023


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DRUG/ DRUG COMBINATION No. ofBrands

PYRAZINAMIDE 40

ETHAMBUTOL 40

RIFABUTIN 2

RIFAMPICIN 22

ETHIONAMIDE 13

ISONIAZID 6

PAS 5

PROTHIONAMIDE 7

STREPTOMYCIN 7

CYCLOSERINE 6

RIFAMPICIN + ISONIAZID 87 87

RIFAMPICIN + ISONIAZIDE + ETHAMBUTOL 40

RIFAMPICIN + ISONIAZIDE + ETHAMBUTOL + PYRAZINAMIDE 54

RIFAMPICIN + ISONIAZIDE + PYRAZINAMIDE 45

ISONIAZIDE + AMINO SALICYLIC ACID 1

ISONIAZID + PYRIDOXINE 4

RIFAMPICIN + ISONIAZIDE + ETHAMBUTOL + PYRAZINAMIDE + PYRIDOXINE 10

PYRAZINAMIDE + ISONIAZID + RIFAMPICIN + PYRIDOXINE 4

ISONIAZIDE + ETHAMBUTOL 12

Total 405

Market promotes irrational treatment


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We know the problems, do we have solutions?

Long term

Expansion of Public Services to ultimately becomethe only provider of TB treatment

Short/Intermediate Term Increase, progressively, the capacity and outreach of

public services Regulation of Private Providers Contracting in private providerswith a public logic Mandatory Continuing Medical Education (CME) for

Doctors Allow only rational formulations to be sold Drug quality assurance


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Thank You

tb in india-role of private sector-amit sengupta phm

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