Medical College Task Force Workshop on NTEP

1. Management of patients seeking
care in the private sector

2. Context
49%
50%
1%
TB care seeking pattern
Government
facility
Private facility
NGO/ Trust
*Source: National TB Prevalence Survey 2019-2021
Service Utilization among consulted for symptoms
Indicator (Jan – Jul 2022) Public Private
TB notification 11,13,486 3,32,898
Bacteriological confirmation
out of TB Notification
654455 (59%) 97526 (29%)
RR status known 497622 (76%) 69215 (71%)
MDR/RR-TB put on Rx 31831 (90%) 1991 (80%)
Treatment success rate of
MDR/RR-TB (Jan–Jun 20)
65% 67%
Infrastructure Public Private (engaged)
NAAT 4760 ?
LPA
• FL-LPA
• SL-LPA
63
56
10
5
LC-DST
• First line
• Second line
51
44
9
5
DR-TB centre 749 27

3. Medical college <> Private healthcare
• Medical colleges – mentor for
private health care practitioners
• Private medical colleges – 306
• Faculties in medical colleges –
practice in private sector
• Actions to improve
quality protocol,
processes, &
continuum of care
Care within private
sector
• Linkages for care to
NTEP
Referral for care of
patients from
private sector

4. General principles
Responsibility of the NTEP is to reach out to all
private providers and generate demand for free of
cost services including drugs, diagnostics and
patient support available through the
programme.
o The availability of these services should always be
explained to the private providers.
o The decision to avail these services depends on the
willingness of the patient and provider.
o The NTEP may use PPSA or other agencies engaged
through purchase of service agreement to reach out
to all patients
4
Processes
• CMEs, Difficult to treat
clinics, clinical summits
• One-to-one meetings
• Linkages
• Coordination through
interface agency (PPSA)

5. Diagnostic services for private sector
• Private health care facilities should be encouraged to avail and
provide free and quality diagnostic services (NTEP) to patients
• If providers agree, NTEP should set up linkages
• Reference laboratory
• Sample collection centres
• Sample transport services
• Reporting mechanism
• Linkages to treatment
Lab preparedness
• Lab staff informed
• Availability of consumables
• Lab capacity

6. Diagnostics services in private sector…
• There are laboratories in private sector with capacities of diagnosing TB and DR-
TB – NTEP can utilize these labs for expanding services
Modalities of engagement
6
Purchasing of
services
• As per the
requirement of
state
• Partnership
guidance
Quality assurance
• Certification of
labs
• Proficiency testing
• Training/mentorin
g
Notification &
reporting
• Labs & sample
collection centres
• Transfer of
patients

7. DS-TB Treatment in/for Private Sector
If the private health facility or provider,
• has the capacity to initiate an appropriate TB
treatment regimen as per NTEP guidelines
• is willing to dispense NTEP provided ATT drugs,
Efforts should be made to partner with such provider or
facility to serve as a treatment centre
• Supply ATT drugs to the facility
• Train and orient staff on dispensation and recording 7
Drug supply to
i. Private doctor
ii. Private chemist
Treatment supporter
i. Private provider can be
treatment supporter
ii. Incentives of treatment
supporter
TB patients diagnosed in the private sector may wish to avail treatment services from
the public sector  Linkages of referral, transfer and treatment support by NTEP

8. DR-TB patients referred for treatment from private sector
• NTEP strongly recommends bacteriological confirmation of any DR-TB patients before
initiation of treatment.
• DST results available from private laboratories for such patients will be considered acceptable
if-
o NAAT results from labs that regularly undertake annual calibration of machines and/or are a part of
the EQA mechanism of quality assurance under NTEP; and
o C&DST labs cleared the annual proficiency testing through NRLs and certified under NTEP for
respective DST technology.
• If results are not in accordance with the above, DST would be offered under NTEP.
• If no bacteriological confirmation is possible due to lack of specimen, decision to treat for DR-
TB may be taken. This can be done in consultation with the DR-TB Committee.
8

9. DR-TB Treatment in Private Sector
If the private health facility or provider,
• has the capacity to initiate an appropriate DR-TB
treatment regimen as per NTEP guidelines
• is willing to avail treatment support services,
including second-line drugs from NTEP, efforts should
be made to partner with such institutes to serve as a
DR-TB Centre
• State/District Programme Officer can innovate and create
other options also using the guidance from the document.
(Further reading: Guidance document on Partnerships in NTEP 2019)
9
DR-TB treatment
i. DR-TB centre inpatient
services
ii. DR-TB centre on an
outpatient basis
iii. Provision of
consultation charges
for private specialist in
clinical management
in public DR-TBC

10. DR-TB Treatment in Private Sector
• When potential provider/ institute fulfil the requirements to serve as DR-TBC: if willing,
undertake a MoU or agreement with the State/District; the collaboration will be implemented
as per conditions detailed under MoU or agreement.
• When private provider / institute is not in a position to fulfil the requirements of DR-TBC:
their patients can still be provided access to all the PMDT services through a mechanism that
entails engaging with NTEP.
o Linkage should be established with the N/DDR-TBC
o For assessing eligibility for specific regimens, all relevant medical records and reports of the patient
should be shared with N/DDR-TBC to facilitate a decision on the regimen
o DR-TB patients can be initiated on treatment on OPD basis or IPD at N/DDR-TBC
o For continuation of treatment, the private provider can continue to be the treatment supporter
and monitor the patient in close coordination with N/DDR-TBC.
o Complete patient care throughout the treatment course including follow-up schedule, aDSM,
treatment outcomes, long-term follow-up and information exchange as per programme guidelines.
10

11. Hub & spoke model of care… 1
• Private health-care settings have the capacity of
clinical management (diagnose, treat and follow-up) of
drug-resistant TB, such available capacity should be
utilized to expand DR-TB services in such area.
• NTEP may identify private health facilities to function
as a hub or referral centre and organize referral
linkages from other health facilities.
11
Hub
Spoke
1
Spoke
2
Spoke
3
• Clearly demarcate the activities which the spoke and hub would undertake in the TB care
cascade;
• Efforts should be made by DTO to make services from the hub be free of cost.
• A hub agent/TB Mitra may be supported for coordination of DR-TB patients & engagement with
NTEP.

12. Functions of hub and spokes
Functions of hub Functions of spokes
 Manage DR-TB patients as per PMDT
guidelines and standards
 Conduct pre-treatment evaluations
 Treatment as per the latest recommendations
of DR-TB
 Follow-up examination of DR-TB patients
 Manage ADR in DR-TB patients
 Maintain DR-TB treatment register
 Report in Nikshay
 Notify every TB patient in Nikshay
 DST of all notified TB patients
 Patients with DR-TB to be referred to
the Hub
 Maintain referral register
 Facilitate follow-up examination of
patients
 Counselling for adherence support
 Report in Nikshay
12

13. Cascade of care of patient
UDST
(FL & SL)
Counselling and PTE
Treatment initiation
and adherence
support
Follow up clinical
assessment
Bacteriological,
radiological and
biochemical testing
at prescribed
intervals
Interrupter retrieval
Active drug safety
monitoring and
management
(aDSM)
Co-morbidity
management
Nikshay Poshan
Yojana
Contact tracing and
TPT
Recording in
Nikshay
Reporting of
treatment outcome
and Post-treatment
follow-up 13

14. Public health action for notified DR-TB patient
• The responsibility of providing these services rests with the local public health facility-
o either from their own public sector services through established linkages with private facility
directly or
o from purchased services as per the Guidance document on Partnership or
o through PPSA.
• The decision to extend public health action from public sector or through purchased services
would depend on the local context of accessibility of services and patient/provider
willingness.
• Linkages should be established between the private health facility (from where the patient seeks
care) and the facility providing the public health action (public or private).
14
Public health action should be extended to all the patients seeking care in private
sector which includes counselling, contact tracing, TPT to eligible, co-morbidity testing,
nutritional support, adherence support, aDSM monitoring etc.

15. Models of PPP
PPSA • Interface agency – NGO to help
• Private healthcare provider engagement
• Linkages of services
• Public health actions
PPIS (Rajasthan) • Financial incentives direct to private health facilities
• Linkages and support from NTEP
STEPS (Kerala,
Karnataka)
System for TB
elimination in private
sector
• Consortium of private hospitals
• Coalition of professional medical associations
• STEPS centre – single window system to ensure full care cascade (STEPS
coordinator)
FAST (Tamil Nadu)
Find, Assess, Support
and Treatment
• FAST centre – self dependent in public health action
• Consortium includes District administration
• Learning hubs
• Recognitions

16. Thank You