Facilitators and Barriers for Private Health Sector Engagement for TB Care in India: A Systematic Review and Meta-Synthesis of Qualitative Research

Rakesh PS; Mohd Shannawaz; Manu E. Mathew; Kuldeep Singh Sachdeva

doi:10.9745/GHSP-D-24-00034

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PRISMA Flowchart Indicating the Results of Literature Search

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TABLE 1.

Search Terms and Strategies Used to Search Electronic Databases

1	MeSH: Private Hospitals OR Private Sector OR Private Enterprise OR Public Private Partnership OR Public-Private Cooperation OR Public-Private Partnership OR Public-Private Partnerships OR Public-Private Sector Cooperation OR Private Facilities
2	MeSH: Tuberculosis Ti/Ab: (Tuberculosis OR Tuberculoses OR TB)
3	MeSH: India
4	Ti/Ab: (Facilitat* OR Promot* OR Barrier* OR Success OR succeeded OR Issue* OR Factor* OR Concern* OR Hurdle* OR Obstacle* OR Achieve* OR Accomplish* OR Enable* OR learning* OR challenge* OR contrain* OR Enhanc* OR Influenc* OR problem* OR Interfer*)
Search	1 AND 2 AND 3 AND 4

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TABLE 2.

Summary of Themes, Subthemes, and Emergent Codes for Meta-Synthesis of Qualitative Data on Private Sector Engagement in TB Care in India

Overarching Themes	Subthemes	Emergent Codes
Context in which the engagement occurs	Political and economic factors	Stakeholder interests, reasons for poor interest, social responsibility, market forces
	Internal environment of the organizations	NTEP and private sector: value system, vision and goals, organizational structure, culture of organization, stewardship, motivation
	Sociocultural factors	Stigma, confidentiality, patient preferences
Factors that define the architecture of the engagement and its implementation	Strategies for engagement	Policy and dialogue: acceptance Regulatory approach: mandatory TB notification, schedule H1 regulation, social regulations–enablers and concerns Incentives: financial and nonfinancial, enablers and concerns Information exchange: enablers and concerns Public provision of services (drugs, diagnostics, training, public health actions): acceptance, concerns Financing: partnership schemes, strategic purchase, insurance, subsidy
	Mode of engagement	Intermediary agencies, private sector led initiatives, memorandum of understanding, contracts
	Resources for engagement	Human resources: adequacy, workload Other resources: finance, drugs, diagnostics, technological resource, informational resource
	Translation of policies to practice	Knowledge gaps, policy translation to practice, implementation of strategies, procedural hurdles and delays, enablers and barriers
Factors related to the actors implicated in the engagement	Relationship dynamics	Trust, mutual understanding, prior experiences, accountability, positionality
	Capacities to engage	Managerial and technical capacities to engage
	Interaction of actors	Communication, interaction, flexibility, coordination of process, mutuality

Abbreviations: NTEP, National TB Elimination Program.

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TABLE 3.

Summary of Review Findings From the Meta-Synthesis of Qualitative Studies

Review Finding Summary	Studies Contributing to Review Finding	GRADE-CERQual Assessment of Confidence in Evidence	Explanation of CERQual Assessment
1. Private health service delivery sector considered it their professional responsibility to provide quality TB services to all their clients and were committed to contribute to society in fighting TB.	Solomon et al. (2016, 2018),²⁹^,³¹ Nair et al.²⁸ Daftary et al.,²⁶ Rakesh et al.,²⁴ Bharadwaj et al.¹⁷	Moderate	No or minor concerns regarding coherence, moderate concern regarding relevance and adequacy, and minor concern regarding methodological limitations.
2. While engaging with NTEP, formal health care providers in private sector had concerns of “losing their business,” fear of scrutiny of diagnosis and loss of their “autonomy” to diagnose and treat.	Anand et al.,²² Solomon et al. (2016, 2018),²⁹^,³¹ Sairu. et al.,³² Nair et al.,²⁸ Yeole et al.,³³ Ghatage et al.²³	High	No or minor concerns regarding coherence, relevance, adequacy, and methodological limitations.
3. Patients and the private sector doctors had a concern that NTEP is not sensitive to the patient’s confidentiality and privacy.	Anand et al.,²² Rashmi et al.,¹⁶ Sairu et al.,³² Nair et al.,²⁸ Mahasweta et al.,³⁰ Yeole et al.,³³ Ghatage et al.,²³ Shukla et al.,¹⁸ Rupani et al.²⁴	High	No or minor concerns regarding coherence, relevance, adequacy, and methodological limitations.
4. Establishing a single window system inside a private hospital could be a facilitator for improving quality of services to clients with TB.	Archana et al.,²⁷ Rakesh et al.,²⁴ Yeole et al.,³³ Sairu et al.³²	Moderate	No or minor concerns regarding coherence, moderate concern regarding relevance and adequacy, and minor concern regarding methodological limitations.
5. Engaging hospital administrators could be a facilitator for engaging private hospitals.	Nair et al.,²⁸ Rakesh et al.,²⁴ Archana et al.²⁷	Low	No or minor concerns regarding coherence, moderate concern regarding relevance, serious concern regarding adequacy, and minor concern regarding methodological limitations.
6. Judicious use of Schedule H1 drug regulation for anti-TB drugs could enable private sector engagement through identification of right providers.	Rakesh et al.¹⁹	Very low	No or minor concerns regarding coherence, moderate concern regarding relevance, serious concern regarding adequacy, and minor concern regarding methodological limitations.
7. Private hospitals’ and modern medicine practitioners’ motivation to engage was not driven by financial incentives provided by NTEP.	Solomon et al. (2016, 2018),²⁹^,³¹ Nair et al.,²⁸ Rakesh et al.²⁴	Low	Moderate concern regarding coherence, minor concern regarding relevance, moderate concern regarding adequacy, and minor concern regarding methodological limitations.
8. Financial incentive might be useful for engaging informal health care providers and chemists, if provided timely.	Daftary et al.,²⁶ Solomon et al. (2018),²⁹ Kelamane et al.²¹	Low	No or minor concerns regarding coherence, moderate concern regarding relevance, serious concern regarding adequacy, and minor concern regarding methodological limitations.
9. Delay in disbursement of committed funds was very common and it could lead to loss of trust among partners.	Nair et al.,²⁸ Solomon et al.²⁰	Low	No or minor concerns regarding coherence, moderate concern regarding relevance, serious concern regarding adequacy, and minor concern regarding methodological limitations.
10. Private sector considered non-financial incentives like recognition, feedback, involving them in planning and review and giving them equal status in partnership as powerful enablers for their engagement for TB care.	Shukla et al.,¹⁸ Nair et al.,²⁸ Solomon et al.,³¹ Bharadwaj et al.,¹⁷ Rakesh et al.²⁴	High	No or minor concerns regarding coherence, relevance, adequacy, and methodological limitations.
11. Private sector felt that NTEP is demanding “too” much of patient wise data and the system for information exchange needs to be simplified.	Anand at al,²² Rashmi et al.,¹⁶ Sairu et al.,³² Mahasweta et al.,³⁰ Daftary et al.,²⁶ Yeole et al.,³³ Ghatage et al.,²³ Shukla et al.,¹⁹ Bharadwaj et al.,¹⁷ Rupani et al.²⁴	High	No or minor concerns regarding coherence, relevance, adequacy, and methodological limitations.
12. Private-led initiatives to improve quality of TB care such as STEPS had wider acceptance among all stakeholders.	Rakesh et al.²⁴	Very low	No or minor concerns regarding coherence, moderate concern regarding relevance, serious concern regarding adequacy, and minor concern regarding methodological limitations.
13. Lack of coordination mechanisms between public and private sector was a major barrier for private sector engagement.	Anand et al.,²² Sairu et al.,³² Yeloe et al.,³³ Rakesh et al.,²⁴ Shukla et al.¹⁹	High	No or minor concerns regarding coherence, relevance, adequacy and methodological limitations.
14. NTEP staff lacked capacity to deal with private sector and require technical, managerial and soft skill training.	Anand et al.,²² Solomon et al.,²⁹ Karina et al.,³⁴ Nair et al.,²⁸ Mahasweta et al.,³⁰ Yeole et al.³³	High	No or minor concerns regarding coherence, relevance, adequacy, and methodological limitations
15. Lack of uniform understanding regarding private sector engagement among NTEP district officials and field staff hindered the sustainable engagement of private sector for TB care.	Solomon et al. (2018, 2021),²⁹^,³¹ Karina et al.,³⁴ Rakesh et al.²⁴	Very low	No or minor concerns regarding coherence, moderate concern regarding relevance, serious concern regarding adequacy, and minor concern regarding methodological limitations.
16. There was lack of knowledge about the relevant programmatic aspects (e.g., Ni-kshay, misconceptions about notification) among private sector providers.	Yeole et al.,³³ Bharadwaj et al.,¹⁷ Shukla et al.,¹⁸ Archana et al.,²⁷ Sairu et al.,³² Anand et al.,²² Rupani et al.²⁵	High	No or minor concerns regarding coherence, relevance, adequacy and methodological limitations.
17. “Authoritarian” approach of NTEP district-level officials led to inequality in public-private partnerships and was perceived by the private sector as a major barrier for engagement.	Solomon et al. (2016, 2018, 2021),²⁰^,²⁹^,³¹ Nair et al.,²⁸ Sairu et al.³²	Moderate	No or minor concerns regarding coherence, moderate concern regarding relevance and adequacy and minor concern regarding methodological limitations
18. Sustained interaction of NTEP with private sector was an enabler for successful engagement of private sector.	Anand et al.,²² Solomon et al. 2021.²⁰	Very low	No or minor concerns regarding coherence, moderate concern regarding relevance, serious concern regarding adequacy, and minor concern regarding methodological limitations.