STEPS – a patient centric and low-cost solution to ensure standards of TB care to patients reaching private sector in India

Abstract

Background More than half of the TB patients in India seek care from the private sector. Two decades of attempts by the National TB Program to improve collaboration between the public and private sectors have not worked except in a few innovative pilots. The System for TB Elimination in Private Sector (STEPS) evolved in 2019 as a solution to ensure standards of TB care to every patient reaching the private sector. We formally evaluated the STEPS to judge the success of the model in achieving its outcomes and to inform decisions about scaling up of the model to other parts of the country. Methods An evaluation team was constituted involving all relevant stakeholders. A logic framework for the STEPS model was developed. The evaluation focused on (i) processes - whether the activities are taking place as intended and (ii) proximal outcomes - improvements in quality of care and strengthening of TB surveillance system. We (i) visited 30 randomly selected STEPS centres for assessing infrastructure and process using a checklist, (ii) validated the patient data with management information system of National TB Elimination Program (NTEP) by telephonic interview of 57 TB patients (iii) analysed the quality of patient care indicators over 3 years from the management information system (iv) conducted in-depth interviews (IDI) with 33 beneficiaries and stakeholders to understand their satisfaction and perceived benefits of STEPS and (v) performed cost analysis for the intervention from the perspective of NTEP, private hospital and patients. Results Evaluation revealed that STEPS is an acceptable model to all stakeholders. IDIs revealed that all patients were satisfied about the services received. Data in management information system of NTEP were consistent with the hospital records and with the information provided by the patient. Quality of TB care indicators for patients diagnosed in private hospitals showed improvements over years as proportion of TB patients notified from private sector with a microbiological confirmation of diagnosis improved from 25% in 2018 to 38% in 2020 and the documented treatment success rate increased from 33% (2018 cohort) to 88% (2019 cohort). Total additional programmatic cost (deducting cost for patient entitlements) per additional patient with successful treatment outcome was estimated to be 67 USD. Total additional expense/business loss for implementing STEPS for the hospital diagnosing 100 TB patients in a year was estimated to be 573 USD while additional minimum returns for the hospital was estimated to be 1145 USD. Conclusion Evaluation confirmed that STEPS is a low cost and patient-centric strategy. STEPS successfully addressed the gaps in the quality of care for patients seeking care in the private sector and ensured that services are aligned with the standards of TB care. STEPS could be scaled up to similar settings.

Ensuring universal access to quality care for persons with presumed tuberculosis reaching the private sector: lessons from Kerala

“… STEPS [ 29 , 30 ] Government of Kerala, State & District TB Programs, Private Hospital Managements through Private Hospital Consortium, Professional Medical Associations through Coalition of Professional Medical Associations, Project JEET 446 hospitals initiated self-initiated business promotion and customer loyalty services to people with TB, blended with the social responsibility of the private sector [ 30 ]. NTEP provides services customised to each private hospital’s demand for the patients such as free diagnostics, free drugs, domestic air borne infection control kits, support for contact tracing, linkages to social welfare schemes, HIV counselling and testing [ 30 ] Improvement in quality of care to people with TB reaching private sector as evidenced by improvement in (i) microbiological confirmation of cases, (ii) rifampicin resistance testing at baseline, (iii) percentage of those informed of their HIV status, (iii) percentage of those with their treatment outcome reported [ 9 , 30 , 31 ] …”

“…JMM (2019 November, India) visited Kerala and recommended supporting the establishment of STEPS Centres in all private health care facilities [ 15 ]. A formal evaluation of STEPS was conducted by a multi-disciplinary team in 2021 by (i) visiting 30 randomly selected STEPS centres for assessing infrastructure and process using a checklist, (ii) validating the patient data with Ni-kshay by telephonic interview of 57 TB patients (iii) analysing the quality of patient care indicators (iv) conducting in-depth interviews with 33 beneficiaries and stakeholders to understand their satisfaction and perceived benefits and (v) a cost analysis from the perspective of NTEP, private hospital and patients [ 31 ] .…”

Engaging the Private Health Service Delivery Sector for TB Care in India—Miles to Go!

“…The STEPS model is in place in the major hospitals of the southern state of Kerala and a few cities in Karnataka and Tamilnadu. An evaluation revealed that STEPS is a low-cost and patient-centric strategy which successfully addressed the gaps in the quality of care for patients seeking care in the private sector hospitals [ 27 ].…”

“…Corporate/big hospitals : STEPS, which is envisioned as an equal partnership between the public and private sector for the benefit of society, where private hospitals establish systems to improve the quality of TB care, could be a good model for private hospitals [ 27 ]. PPSAs can support the establishing of STEPS in cities where private hospital concentration is higher.…”

Assessing the critical success factors for implementing industry 4.0 in the pharmaceutical industry: Implications for supply chain sustainability in emerging economies

“…Collaborative communication encourages enhanced openness and information sharing, which promote efficient decision-making and improve operational performance. Improved information sharing contributes to increased interconnection, leading to higher responsiveness in removing learning barriers and promoting greater understanding and communication among SC partners to increase sustainability [85]. Among all the CSFs, "advanced database management systems (I2)" and "decentralized management and flexible operations (T6)" had the most negligible impact.…”