Public-private partnership in tuberculosis control: experience in Hyderabad, India.
SETTING: Hyderabad, India. OBJECTIVE: To determine whether private practitioners and the government can collaborate with a nongovernmental intermediary to implement DOTS effectively. DESIGN: A non-profit hospital provided DOTS services to a population of 100000 for 3 years, then expanded coverage to 500000 in October 1998. A hospital physician visited all private practitioners, encouraged them to refer patients, and gave feedback on each patient referred. After diagnosis, patients received directly observed treatment free of charge at the trust hospital or at 30 conveniently located small hospitals operated by local private practitioners. No financial incentives were used to encourage physicians to refer patients or to provide treatment observation. Diagnosis, treatment, and case and outcome definitions were performed as per DOTS policies; medicines and laboratory reagents were provided by the government. RESULTS: All 244 allopathic and 114 non-allopathic physicians practising in the area agreed to participate; 59% referred at least one patient. Of 2244 persons referred, 969 (43%) had tuberculosis. Physicians had obtained chest radiographs on 80% of patients before referral for sputum microscopy. The detection rate increased from 50 to 200/100000 over the first 2-3 years of the project, and has increased gradually since expansion; 90% of new smear-positive patients and 77% of re-treatment patients were successfully treated. Compared with those treated at a neighbouring government DOTS centre, patients in this project paid less for diagnosis ($5 vs. $20) and treatment ($1 vs. $11), largely due to lower transport costs. CONCLUSIONS: Collaborative efforts between private practitioners and the government can achieve moderate-high rates of case detection and high rates of treatment success. Public-private services appeared to be more convenient to patients, who paid less for care and were less likely to miss work in order to participate in DOTS. Clearly defined roles and expectations and frequent communication are essential to success. An institution such as a non-profit hospital can serve as an effective intermediary between the government DOTS programme and private practitioners.