RESUMEN
Background: India's dominant private healthcare sector is the destination for 60-85% of initial tuberculosis care-seeking. The COVID-19 pandemic in India drastically affected TB case notifications in the first half of 2020. In this survey, we assessed the impact of the first wave of COVID-19 in India on private providers, and changes they adopted in their practice due to the pandemic. Methods: The Joint Effort for Elimination of TB (JEET) is a nationwide Global Fund project implemented across 406 districts in 23 states to extend quality TB services to patients seeking care in private sector. We conducted a rapid survey of 11% (2,750) of active providers engaged under JEET's intense Patient Provider Support Agency (PPSA) model across 15 Indian states in Q1 (February-March) of 2021. Providers were contacted in person or telephonically, and consenting participants were interviewed using a web-based survey tool. Responses from participants were elicited on their practice before COVID-19, during the 2020 lockdowns (March-April 2020) and currently (Q1 2021). Data were adjusted for survey design and non-response, and results were summarised using descriptive statistics and logistic regression. Results: Of the 2,750 providers sampled, 2,011 consented and were surveyed (73 % response). Nearly 50 % were between 30 and 45 years of age, and 51 % were from Uttar Pradesh, Maharashtra and Gujarat. Seventy percent of providers reported reduced daily out-patient numbers in Q1 2021 compared to pre-COVID times. During the lockdown, 898 (40 %) of providers said their facilities were closed, while 323 (11 %) offered limited services including teleconsultation. In Q1 2021, 88 % of provider facilities were fully open, with 10 % providing adjusted services, and 4 % using teleconsultation. Only 2 % remained completely closed. Majority of the providers (92 %) reported not experiencing any delays in TB testing in Q1 2021 compared to pre-COVID times. Only 6 % reported raising costs at their clinic, mostly to cover personal protective equipment (PPE) and other infection control measures, although 60-90 % implemented various infection control measures. Thirty-three percent of TB providers were ordering COVID-19 testing, in addition to TB testing.To adapt, 82% of survey providers implemented social distancing and increased timing between appointments and 83% started conducting temperature checks, with variation by state and provider type, while 89% adopted additional sanitation measures in their facilities. Furthermore, 62% of providers started using PPE, and 13% made physical changes (air filters, isolation of patient areas) to their clinic to prevent infection. Seventy percent of providers stated that infection control measures could decrease TB transmission. Conclusion: Although COVID-19 restrictions resulted in significant declines in patient turn-out at private facilities, our analysis showed that most providers were open and costs for TB care remained mostly the same in Q1 2021. As result of the COVID-19 pandemic, several positive strategies have been adapted by the private sector TB care providers. Since the subsequent COVID-19 waves were more severe or widespread, additional work is needed to assess the impact of the pandemic on the private health sector.
RESUMEN
BACKGROUND: India carries one-fourth of the global tuberculosis (TB) burden. Hence the country has drafted the ambitious National Strategic Plan to eliminate tuberculosis by 2025. To realise this goal, India's Revised National Tuberculosis Control Programme (RNTCP) and partners piloted a novel strategy to engage private-providers for tuberculosis care via a "Private-provider Interface Agency" (PPIA) in Mumbai and other locations. INTERVENTION: The program mapped and engaged private-providers, chemists, and laboratories; facilitated TB notification via call centers and field staff; provided free tuberculosis diagnostic tests and anti-TB drugs using novel electronic vouchers; monitored quality of care; and supported patients to ensure anti-TB treatment adherence and completion. This report summarises the descriptive analysis of PPIA implementation data piloted in Mumbai from 2014 to 2017. FINDINGS: The program mapped 8789 private doctors, 3438 chemists, and 985 laboratories. Of these, 3836 (44%) doctors, 285 (29%) laboratories, and 353 (10%) chemists were prioritized and engaged in the program. Over three and a half years, the program recorded 60,366 privately-notified tuberculosis patients, of which, 24,146 (40%) were microbiologically-confirmed, 5203 (9%) were rifampicin-resistant, and 4401 (7%) were paediatric TB patients. Mumbai's annual total TB case notification rate increased from a pre-program baseline of 272 per 100,000/year in 2013 to 416 per 100,000/year in 2017. Overall, 42,300 (78%) patients completed the TB treatment, and 4979 (9%) could not be evaluated. INTERPRETATION: The PPIA program in Mumbai demonstrated that private-providers can be effectively engaged for TB control in urban India. This program has influenced national policy and has been adapted and funded for a country-wide scale up. The model may also be considered in conditions where private-provider engagement is needed to improve access and quality of care for any area of public health.