Fighting diseases

What India needs to do to win the fight against tuberculosis

The way forward is to invest in TB control, take public health benefits – free drugs and testing – to the unknown number of privately-treated patients.

India reports more cases of tuberculosis than any other country. This much is well known. However, nobody quite knows the true magnitude of the TB problem in the country. For one, we do not know the number of TB patients who do not seek care or remain undiagnosed, but we refer to this often as the “missing million”. Also, until recently, we did not have the foggiest idea of the number of TB patients treated in India’s vast, fragmented private sector. Currently, many private providers and hospitals do not notify TB cases to the government, despite TB being made a notifiable disease in 2012.

This can change. There is now a significant opportunity to scale up systems for private providers to notify TB cases, for patients to benefit from free, essential services, and for the government to correctly count all public and private TB cases so that we get to know how well disease control is working, creating a win-win-win situation for all.

A series of studies that we contributed to, published in The Lancet Infectious Diseases, provide several new insights into TB in the private sector, and might help direct strategies for tackling the disease. In the first study, the researchers took advantage of a unique data window into the private sector – a large, national database on the sales and distribution of anti-tuberculosis drugs in the private sector. The analysis suggested that 2.2 million cases could plausibly have been treated in the private sector alone in 2014, more than double the number suggested by previous estimates. This shows the sheer scale of the effort that will be required to reach private providers, and attract notifications for privately-treated TB patients.

The other studies provided useful insight into who exactly was prescribing these enormous quantities of TB medicines. Here, the researchers used simulated patients, presenting classic TB symptoms or documented evidence of TB disease, to assess what various providers actually did when faced with such patients. The results of these studies clearly showed that, at least in urban areas, allopathic private doctors are treating TB. Reassuringly, informal and AYUSH practitioners rarely dispensed anti-tuberculosis drugs and pharmacists never dispensed them over the counter. However, these providers rarely tested for TB even when patients presented typical symptoms or abnormal chest x-rays. Thus, while they may not be misusing TB drugs, they may be contributing to delays in TB diagnosis by using other antibiotics and non-specific therapies.

Improving outreach

These studies come at a time when India’s Revised National TB Control Programme and state and city governments have succeeded in demonstrating innovative, workable and scalable solutions. In several settings, the RNTCP has effectively engaged private providers, successfully attracting large numbers of private TB case notifications.

With that information, the RNTCP has improved diagnosis of patients with free tests, provided patients free TB drugs, and extended adherence support to increase rates of TB treatment completion. These innovative approaches are bringing previously invisible, privately-treated TB patients into the light of public health services, where care and adherence can be monitored. Thanks to the information and communications technologies deployed, these projects are also generating unprecedented data on TB outcomes in the private sector.

Private providers engaged in these projects are seeing the value their TB patients are getting via free test vouchers, free TB drugs, and continuous support and counseling to ensure treatment completion. This value, in turn, helps them retain their patients, secure their respect, and grow their practice. Private practitioners also appreciate the direct human contact they have with public health workers, getting feedback on how their patients are progressing, and helping their patients sustain a full course of treatment. Most importantly, they appreciate being made a partner in their city’s TB control effort.

To scale up these effective interventions to reach all TB patients, it is critical for the government to take TB control as a genuine mission and make serious financial investments. Simply put, treating twice as many TB patients will cost twice the budget currently being provided. And that should be a fantastic investment for the nation, because TB control is a very cost-effective strategy with exceptional returns on investment from a societal perspective. From an economic perspective, investing in the Global Plan to End TB is estimated to deliver India $364 billion as overall economic return. Any plan to end TB in India must include a comprehensive approach to partnering with the private sector. Otherwise, more than half the TB burden in the country will be left unaddressed.

Following China's lead

Equally importantly, TB patients cannot remain invisible. There is a need for more robust estimates of TB burden and continued efforts to measure quality of care in the private sector.

Countries such as China have made serious investments in TB control, effectively used repeated rounds of national TB prevalence surveys to track their TB epidemic, and have shown major reductions in prevalence over time.

India needs to do the same, and we applaud the direct disease burden estimation that the RNTCP has proposed via a national TB prevalence survey. But prevalence estimation is not enough, the TB programme needs to track and support individuals with TB. The RNTCP’s e-Nikshay TB case notification system offers hope that case notifications can result in meaningful public health action. This will require investments in information and communications technology infrastructure and real-time data intelligence.

Lastly, leadership is critical and India is starting to step up. The government has taken several steps over the past few years to address TB. This includes making TB a notifiable disease, developing the Standards for TB Care in India, introducing daily drug regimens, and molecular and drug susceptibility testing. But there is an opportunity to do more and better, and for India to assume a global leadership role. With its strong research expertise in TB, biotech and IT capacity, and recent successes (for example, polio elimination, indigenous rotavirus vaccine), India has the potential to lead from the front. With strong financial and political commitment from Prime Minister Narendra Modi and his cabinet, India can take on tuberculosis.

Madhukar Pai is a Canada Research Chair of Epidemiology & Global Health at McGill University, Montreal, where he directs Global Health Programmes.

Nimalan Arinaminpathy is Senior Lecturer in the Department of Infectious Disease Epidemiology, in the School of Public Health, at Imperial College, London

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What hospitals can do to drive entrepreneurship and enhance patient experience

Hospitals can perform better by partnering with entrepreneurs and encouraging a culture of intrapreneurship focused on customer centricity.

At the Emory University Hospital in Atlanta, visitors don’t have to worry about navigating their way across the complex hospital premises. All they need to do is download wayfinding tools from the installed digital signage onto their smartphone and get step by step directions. Other hospitals have digital signage in surgical waiting rooms that share surgery updates with the anxious families waiting outside, or offer general information to visitors in waiting rooms. Many others use digital registration tools to reduce check-in time or have Smart TVs in patient rooms that serve educational and anxiety alleviating content.

Most of these tech enabled solutions have emerged as hospitals look for better ways to enhance patient experience – one of the top criteria in evaluating hospital performance. Patient experience accounts for 25% of a hospital’s Value-Based Purchasing (VBP) score as per the US government’s Centres for Medicare and Mediaid Services (CMS) programme. As a Mckinsey report says, hospitals need to break down a patient’s journey into various aspects, clinical and non-clinical, and seek ways of improving every touch point in the journey. As hospitals also need to focus on delivering quality healthcare, they are increasingly collaborating with entrepreneurs who offer such patient centric solutions or encouraging innovative intrapreneurship within the organization.

At the Hospital Leadership Summit hosted by Abbott, some of the speakers from diverse industry backgrounds brought up the role of entrepreneurship in order to deliver on patient experience.

Getting the best from collaborations

Speakers such as Dr Naresh Trehan, Chairman and Managing Director - Medanta Hospitals, and Meena Ganesh, CEO and MD - Portea Medical, who spoke at the panel discussion on “Are we fit for the world of new consumers?”, highlighted the importance of collaborating with entrepreneurs to fill the gaps in the patient experience eco system. As Dr Trehan says, “As healthcare service providers we are too steeped in our own work. So even though we may realize there are gaps in customer experience delivery, we don’t want to get distracted from our core job, which is healthcare delivery. We would rather leave the job of filling those gaps to an outsider who can do it well.”

Meena Ganesh shares a similar view when she says that entrepreneurs offer an outsider’s fresh perspective on the existing gaps in healthcare. They are therefore better equipped to offer disruptive technology solutions that put the customer right at the center. Her own venture, Portea Medical, was born out of a need in the hitherto unaddressed area of patient experience – quality home care.

There are enough examples of hospitals that have gained significantly by partnering with or investing in such ventures. For example, the Children’s Medical Centre in Dallas actively invests in tech startups to offer better care to its patients. One such startup produces sensors smaller than a grain of sand, that can be embedded in pills to alert caregivers if a medication has been taken or not. Another app delivers care givers at customers’ door step for check-ups. Providence St Joseph’s Health, that has medical centres across the U.S., has invested in a range of startups that address different patient needs – from patient feedback and wearable monitoring devices to remote video interpretation and surgical blood loss monitoring. UNC Hospital in North Carolina uses a change management platform developed by a startup in order to improve patient experience at its Emergency and Dermatology departments. The platform essentially comes with a friendly and non-intrusive way to gather patient feedback.

When intrapreneurship can lead to patient centric innovation

Hospitals can also encourage a culture of intrapreneurship within the organization. According to Meena Ganesh, this would mean building a ‘listening organization’ because as she says, listening and being open to new ideas leads to innovation. Santosh Desai, MD& CEO - Future Brands Ltd, who was also part of the panel discussion, feels that most innovations are a result of looking at “large cultural shifts, outside the frame of narrow business”. So hospitals will need to encourage enterprising professionals in the organization to observe behavior trends as part of the ideation process. Also, as Dr Ram Narain, Executive Director, Kokilaben Dhirubhai Ambani Hospital, points out, they will need to tell the employees who have the potential to drive innovative initiatives, “Do not fail, but if you fail, we still back you.” Innovative companies such as Google actively follow this practice, allowing employees to pick projects they are passionate about and work on them to deliver fresh solutions.

Realizing the need to encourage new ideas among employees to enhance patient experience, many healthcare enterprises are instituting innovative strategies. Henry Ford System, for example, began a system of rewarding great employee ideas. One internal contest was around clinical applications for wearable technology. The incentive was particularly attractive – a cash prize of $ 10,000 to the winners. Not surprisingly, the employees came up with some very innovative ideas that included: a system to record mobility of acute care patients through wearable trackers, health reminder system for elderly patients and mobile game interface with activity trackers to encourage children towards exercising. The employees admitted later that the exercise was so interesting that they would have participated in it even without a cash prize incentive.

Another example is Penn Medicine in Philadelphia which launched an ‘innovation tournament’ across the organization as part of its efforts to improve patient care. Participants worked with professors from Wharton Business School to prepare for the ideas challenge. More than 1,750 ideas were submitted by 1,400 participants, out of which 10 were selected. The focus was on getting ideas around the front end and some of the submitted ideas included:

  • Check-out management: Exclusive waiting rooms with TV, Internet and other facilities for patients waiting to be discharged so as to reduce space congestion and make their waiting time more comfortable.
  • Space for emotional privacy: An exclusive and friendly space for individuals and families to mourn the loss of dear ones in private.
  • Online patient organizer: A web based app that helps first time patients prepare better for their appointment by providing check lists for documents, medicines, etc to be carried and giving information regarding the hospital navigation, the consulting doctor etc.
  • Help for non-English speakers: Iconography cards to help non-English speaking patients express themselves and seek help in case of emergencies or other situations.

As Arlen Meyers, MD, President and CEO of the Society of Physician Entrepreneurs, says in a report, although many good ideas come from the front line, physicians must also be encouraged to think innovatively about patient experience. An academic study also builds a strong case to encourage intrapreneurship among nurses. Given they comprise a large part of the front-line staff for healthcare delivery, nurses should also be given the freedom to create and design innovative systems for improving patient experience.

According to a Harvard Business Review article quoted in a university study, employees who have the potential to be intrapreneurs, show some marked characteristics. These include a sense of ownership, perseverance, emotional intelligence and the ability to look at the big picture along with the desire, and ideas, to improve it. But trust and support of the management is essential to bringing out and taking the ideas forward.

Creating an environment conducive to innovation is the first step to bringing about innovation-driven outcomes. These were just some of the insights on healthcare management gleaned from the Hospital Leadership Summit hosted by Abbott. In over 150 countries, Abbott, which is among the top 100 global innovator companies, is working with hospitals and healthcare professionals to improve the quality of health services.

To read more content on best practices for hospital leaders, visit Abbott’s Bringing Health to Life portal here.

This article was produced on behalf of Abbott by the Scroll.in marketing team and not by the Scroll.in editorial staff.