Date Published: June 5, 2019
Publisher: Public Library of Science
Author(s): Sarang Deo, Pankaj Jindal, Devesh Gupta, Sunil Khaparde, Kiran Rade, Kuldeep Singh Sachdeva, Bhavin Vadera, Daksha Shah, Kamlesh Patel, Paresh Dave, Rishabh Chopra, Nita Jha, Sirisha Papineni, Shibu Vijayan, Puneet Dewan, Yong-Hong Kuo.
Private providers dominate health care in India and provide most tuberculosis (TB) care. Yet efforts to engage private providers were viewed as unsustainably expensive. Three private provider engagement pilots were implemented in Patna, Mumbai and Mehsana in 2014 based on the recommendations in the National Strategic Plan for TB Control, 2012–17. These pilots sought to improve diagnosis and treatment of TB and increase case notifications by offering free drugs and diagnostics for patients who sought care among private providers, and monetary incentives for providers in one of the pilots. As these pilots demonstrated much higher levels of effectiveness than previously documented, we sought to understand program implementation costs and predict costs for their national scale-up.
We developed a common cost structure across these three pilots comprising fixed and variable cost components. We conducted a retrospective, activity-based costing analysis using programmatic data and qualitative interviews with the respective program managers. We estimated the average recurring costs per TB case at different levels of program scale for the three pilots. We used these cost estimates to calculate the budget required for a national scale up of such pilots. The average cost per privately-notified TB case for Patna, Mumbai and Mehsana was estimated to be US$95, US$110 and US$50, respectively, in May 2016 when these pilots were estimated to cover 50%, 36% and 100% of the total private TB patients, respectively. For Patna and Mumbai pilots, the average cost per case at full scale, i.e. 100% coverage of private TB patients, was projected to be US$91 and US$101, respectively. In comparison, the national TB program’s budget for 2015 averages out to $150 per notified TB case. The total annual additional budget for a national scale up of these pilots was estimated to be US$267 million.
As India seeks to eliminate TB, extensive national engagement of private providers will be required. The cost per privately-notified TB case from these pilots is comparable to that already being spent by the public sector and to the projected cost per privately-notified TB case required to achieve national scale-up of these pilots. With additional funds expected to execute against national TB elimination commitments, the scale-up costs of these operationally viable and effective private provider engagement pilots are likely to be financially viable.
India bears the largest portion of tuberculosis (TB) disease burden in the world in terms of incidence, prevalence, and mortality . Of the 2.6 to 6.8 million estimated cases in India in 2014, 1.2 to 5.3 million cases (46–79%) were estimated to be treated in the private sector (either for-profit or not-for-profit non-government providers), but only 0.2 million (4–16%) of these were notified [2, 3]. TB diagnostic and treatment practices by private providers have been repeatedly found to be far short of the national standard guidelines [4–7]. Several Public-Private Mix (PPM) models, aimed at promoting standard TB care practices and encouraging referral of diagnosed TB cases to the public sector among private providers, have been implemented by the Revised National TB Control Program (RNTCP) [7–11]. These models contributed only 0.5%–2.5% of the estimated cases in the private sector in 2014 [1, 12–15]. It has been conjectured that public sector activities have been prioritized over private provider engagement, leading to a low uptake of any models or schemes for private provider engagement [15–17]. Moreover, providers who are aware of PPM models may limit their involvement due to restrictions on prescription of TB treatment , from fear of losing their revenues to the public sector through patient referrals [13, 14, 16, 18, 19], or from concerns about the quality and access of care available to patients at public facilities .
Fig 3 displays retrospective estimates as well as prospective projections of the average cost per case in Patna, Mumbai and Mehsana. In May 2016, the estimated average cost per case was US$95 and US$110 for Patna and Mumbai pilots at population coverage ratios of 50% and 36%, respectively. For Mehsana pilot, which provided fewer diagnostic services and had already reached close to 100% population coverage ratio in May 2016, the average cost per case was estimated to be US$50. For Patna and Mumbai pilots, the average cost per case at 100% population coverage was estimated to be US$91 and US$101, respectively. At 100% coverage, the commodity cost per case was estimated to be US$58, US$67 and US$30 whereas the programmatic cost per case was estimated to be US$33, US$34 and US$21 for Patna, Mumbai and Mehsana, respectively. The largest component of cost was commodity cost (drugs and diagnostics for Patna and Mumbai, drugs for Mehsana) followed by field staff (for Patna and Mumbai) and ICT costs.
Innovative models, such as interfacing agencies, have been proposed as a potential mechanism for large scale private sector engagement for TB diagnosis and treatment in India. In this paper, we take the first step towards obtaining a realistic estimate of the budget required for a successful national scale up of such models. Towards this end, we used a detailed programmatic understanding to conduct a cost analysis of the three UATBC pilots implemented in Patna, Mumbai and Mehsana. Our results suggest that, at full scale, i.e., 100% population coverage, the average recurring cost per case would be between US$90 and US$100 for urban pilots (e.g. Mumbai and Patna) and around US$50 for rural pilots (e.g. Mehsana).