Engaging for-profit providers in TB control: lessons learnt from initiatives in South Asia.

There has been a huge expansion in the private health-care sector over the past two decades, particularly in South Asia, resulting in over 80% of patients seeking care from private health providers. Despite concerns about the quality and equity of private sector service provision, most government public health bodies recognize that the private sector reaches individuals that public institutions cannot cater to, thereby being important in moving closer to universal health coverage. Numerous initiatives have been launched and are being planned to involve private practitioners in effectively diagnosing, reporting and managing infectious diseases such as tuberculosis. However, there is a notable dearth of papers discussing which elements of private sector engagement strategies are more or less successful and the ethical issues that arise when engagement strategies are operationalized. This article brings together the authors' experiences of working on projects to engage private allopathic health providers in Pakistan, Bangladesh and India for improved tuberculosis control. Motivations of and strategies required to engage private allopathic heath providers, specifically doctors, diagnostic laboratories and pharmacies, and some of the ethical issues that arise when designing programmes for engagement are discussed

Understanding the complex relationships among actors involved in the implementation of public-private mix (PPM) for TB control in India, using social theory.

BACKGROUND: Public Private Partnerships (PPP) are increasingly utilized as a public health strategy for strengthening health systems and have become a core component for the delivery of TB control services in India, as promoted through national policy. However, partnerships are complex systems that rely on relationships between a myriad of different actors with divergent agendas and backgrounds. Relationship is a crucial element of governance, and relationship building an important aspect of partnerships. To understand PPPs a multi-disciplinary perspective that draws on insights from social theory is needed. This paper demonstrates how social theory can aid the understanding of the complex relationships of actors involved in implementation of Public-Private Mix (PPM)-TB policy in India. METHODS: Ethnographic research was conducted within a district in a Southern state of India over a 14 month period, combining participant observations, informal interactions and in-depth interviews with a wide range of respondents across public, private and non-government organisation (NGO) sectors. RESULTS: Drawing on the theoretical insights from Bourdieu's "theory of practice" this study explores the relationships between the different actors. The study found that programme managers, frontline TB workers, NGOs, and private practitioners all had a crucial role to play in TB partnerships. They were widely regarded as valued contributors with distinct social skills and capabilities within their organizations and professions. However, their potential contributions towards programme implementation tended to be unrecognized both at the top and bottom of the policy implementation chain. These actors constantly struggled for recognition and used different mechanisms to position themselves alongside other actors within the programme that further complicated the relationships between different actors. CONCLUSION: This paper demonstrates that applying social theory can enable a better understanding of the complex relationship across public, private and NGO sectors. A closer understanding of these processes is a prerequisite for bridging the gap between field-level practices and central policy intentions, facilitating a move towards more effective partnership strategies for strengthening local health systems. The study contributes to our understanding of implementation of PPP for TB control and builds knowledge to help policy makers and programme managers strengthen and effectively implement strategies to enable stronger governance of these partnerships

Health systems’ responses to the roll-out of antiretroviral therapy (ART) in India: a comparison of two HIV high-prevalence settings

The government of India launched the free anti-retroviral therapy (ART) initiative in 2004 and the programme has since scaled up expansion in a phased manner. Programme authorities acknowledge problems in scale-up, yet discussions have been restricted to operational constraints, with little consideration for how local health system responses to HIV/AIDS influence the delivery of ART. This paper draws on the perspectives of key informants and people living with HIV (PLHIV) to compare delivery of ART in two ART centres in the States of Maharashtra and Andhra Pradesh at two distinct points of time. In 2005, data were collected through key informant interviews (KIIs) using interview guides and a survey of PLHIV using a semi-structured interview schedule. Differences were observed in the functioning and resources of the two centres, indicating different levels of preparedness which in turn influenced PLHIV's pathways in accessing ART. We examine these differences in the light of programme leadership, ownership and the roles of public, private and non-governmental organisation actors in HIV care. KIIs conducted during a follow-up visit in 2009 focused on changes in ART delivery. Many operational problems had been resolved; however, new challenges were emerging as a result of the increased patient load. An understanding of how ART programmes evolve within local health systems has bearing on future developments of the ART programme and must include a consideration of the wider socio-political environment within which HIV programmes are embedded

Private Practitioners’ Perspectives on Their Involvement With the Tuberculosis Control Programme in a Southern Indian State

Background: Public and private health sectors both play a crucial role in the health systems of low- and middleincome countries (LMICs). The tuberculosis (TB) control strategy in India encourages the public sector to actively partner with private practitioners (PPs) to improve the quality of front line service delivery. However, ensuring effective and sustainable involvement of PPs constitutes a major challenge. This paper reports the findings from an empirical study focusing on the perspectives and experiences of PPs towards their involvement in TB control programme in India. Methods: The study was carried out between November 2010 and December 2011 in a district of a Southern Indian State and utilised qualitative methodologies, combining observations and in-depth interviews with 21 PPs from different medical systems. The collected data was coded and analysed using thematic analysis. Results: PPs perceived themselves to be crucial healthcare providers, with different roles within the public-private mix (PPM) TB policy. Despite this, PPs felt neglected and undervalued in the actual process of implementation of the PPM-TB policy. The entire process was considered to be government driven and their professional skills and knowledge of different medical systems remained unrecognised at the policy level, and weakened their relationship and bond with the policy and with the programme. PPs had contrasting perceptions about the different components of the TB programme that demonstrated the public sector’s dominance in the overall implementation of the DOTS strategy. Although PPs felt responsible for their TB patients, they found it difficult to perceive themselves as ‘partners with the TB programme.’ Conclusion: Public-private partnerships (PPPs) are increasingly utilized as a public health strategy to strengthen health systems. These policies will fail if the concerns of the PPs are neglected. To ensure their long-term involvement in the programme the abilities of PPs and the important perspectives from other Indian medical systems need to be recognised and supporte

Community health workers and Covid-19: Cross-country evidence on their roles, experiences, challenges and adaptive strategies

Community health workers (CHWs) are a key part of the health workforce, with particular importance for reaching the most marginalised. CHWs’ contributions during pandemics have received growing attention, including for COVID-19. This paper contributes to learning about CHWs’ experiences during COVID-19, based on evidence from India, Bangladesh, Pakistan, Sierra Leone, Kenya and Ethiopia. The paper synthesises evidence from a set of research projects undertaken over 2020–2021. A thematic framework based on the research focus and related literature was used to code material from the reports. Following further analysis, interpretations were verified with the original research teams. CHWs made important contributions to the COVID-19 response, including in surveillance, community education, and support for people with COVID-19. There was some support for CHWs’ work, including training, personal protective equipment and financial incentives. However, support varied between countries, cadres and individual CHWs, and there were significant gaps, leaving CHWs vulnerable to infection and stress. CHWs also faced a range of other challenges, including health system issues such as disrupted medical supply chains, insufficient staff and high workloads, a particular difficulty for female CHWs who were balancing domestic responsibilities. Their work was also affected by COVID-19 public health measures, such as restrictions on gatherings and travel; and by supply-side constraints related to community access and attitudes, including distrust and stigmatization of CHWs as infectious or informers. CHWs demonstrated commitment in adapting their work, for example ensuring patients had adequate drugs in advance of lockdowns, and using their own money and time to address increased transport costs and higher workloads. Effectiveness of these adaptations varied, and some involved coping in a context of inadequate support. CHW are critical for effective response to disease outbreaks, including pandemics like COVID-19. To support CHWs’ contribution and protect their wellbeing, CHWs need adequate resources, managerial support, and motivation

Private Practitioners’ Perspectives on Their Involvement With the Tuberculosis Control Programme in a Southern Indian State

Background Public and private health sectors both play a crucial role in the health systems of low- and middleincome countries (LMICs). The tuberculosis (TB) control strategy in India encourages the public sector to actively partner with private practitioners (PPs) to improve the quality of front line service delivery. However, ensuring effective and sustainable involvement of PPs constitutes a major challenge. This paper reports the findings from an empirical study focusing on the perspectives and experiences of PPs towards their involvement in TB control programme in India. Methods The study was carried out between November 2010 and December 2011 in a district of a Southern Indian State and utilised qualitative methodologies, combining observations and in-depth interviews with 21 PPs from different medical systems. The collected data was coded and analysed using thematic analysis. Results PPs perceived themselves to be crucial healthcare providers, with different roles within the public-private mix (PPM) TB policy. Despite this, PPs felt neglected and undervalued in the actual process of implementation of the PPM-TB policy. The entire process was considered to be government driven and their professional skills and knowledge of different medical systems remained unrecognised at the policy level, and weakened their relationship and bond with the policy and with the programme. PPs had contrasting perceptions about the different components of the TB programme that demonstrated the public sector’s dominance in the overall implementation of the DOTS strategy. Although PPs felt responsible for their TB patients, they found it difficult to perceive themselves as ‘partners with the TB programme.’ Conclusion Public-private partnerships (PPPs) are increasingly utilized as a public health strategy to strengthen health systems. These policies will fail if the concerns of the PPs are neglected. To ensure their long-term involvement in the programme the abilities of PPs and the important perspectives from other Indian medical systems need to be recognised and supported

Evidence and gap map report: Social and Behavior Change Communication (SBCC) interventions for strengthening HIV prevention and research among adolescent girls and young women (AGYW) in low‐ and middle‐income countries (LMICs)

Abstract Background Adolescent girls and young women (AGYW), aged 15–24 years, are disproportionately affected by HIV and other sexual and reproductive health (SRH) risks due to varying social, cultural, and economic factors that affect their choices and shape their knowledge, understanding, and practices with regard to their health. Socio‐Behavioral Change Communication (SBCC) interventions targeted at strengthening the capabilities of individuals and their networks have supported the demand and uptake of prevention services and participation in biomedical research. However, despite growing global recognition of the domain, high‐quality evidence on the effectiveness of SBCC remains scattered. This evidence and gap map (EGM) report characterizes the evidence base on SBCC interventions for strengthening HIV Prevention and Research among AGYW in low‐ and middle‐income countries (LMICs), identifying evidence gaps and outlining the scope of future research and program design. Objectives The objectives of the proposed EGM are to: (a) identify and map existing EGMs in the use of diverse SBCC strategies to strengthen the adoption of HIV prevention measures and participation in research among AGYW in LMICs and (b) identify areas where more interventions and evidence are needed to inform the design of future SBCC strategies and programs for AGYW engagement in HIV prevention and research. Methods This EGM is based on a comprehensive search of systematic reviews and impact evaluations corresponding to a range of interventions and outcomes—aimed at engaging AGYW in HIV prevention and research ‐ that were published in LMICs from January 2000 to April 2021. Based on guidance for producing a Campbell Collaboration EGM, the intervention and outcome framework was designed in consultation with a group of experts. These interventions were categorized across four broad intervention themes: mass‐media, community‐based, interpersonal, and Information Communication and Technology (ICT)/Digital Media‐based interventions. They were further sub‐categorized into 15 intervention categories. Included studies looked at 23 unique behavioral and health outcomes such as knowledge attitude and skills, relationship dynamics, household dynamics, health care services, and health outcomes and research engagement. The EGM is presented as a matrix in which the rows are intervention categories/sub‐categories, and the columns are outcome domains/subdomains. Each cell is mapped to an intervention targeted at outcomes. Additional filters like region, country, study design, age group, funding agency, influencers, population group, publication status, study confidence, setting, and year of publication have been added. Selection Criteria To be eligible, studies must have tested the effectiveness of SBCC interventions at engaging AGYW in LMICs in HIV prevention and research. The study sample must have consisted of AGYW between the ages of 15–24, as defined by UNAIDS. Both experimental (random assignment) and quasi‐experimental studies that included a comparison group were eligible. Relevant outcomes included those at the individual, influencer, and institutional levels, along with those targeting research engagement and prevention‐related outcomes. Results This EGM comprises 415 impact evaluations and 43 systematic reviews. Interventions like peer‐led interactions, counseling, and community dialogues were the most dominant intervention sub‐types. Despite increased digital penetration use of media and technology‐driven interventions are relatively less studied. Most of the interventions were delivered by peers, health care providers, and educators, largely in school‐based settings, and in many cases are part of sex‐education curricula. Evidence across geographies was mostly concentrated in Sub‐Saharan Africa (70%). Most measured outcomes focused on disease‐related knowledge dissemination and enhancing awareness of available prevention options/strategies. These included messaging around consistent condom use, limiting sexual partners, routine testing, and awareness. Very few studies were able to include psychographic, social, and contextual factors influencing AGYW health behaviors and decisions, especially those measuring the impact of social and gender norms, relationship dynamics, and household dynamics‐related outcomes. Outcomes related to engagement in the research were least studied. Conclusion This EGM highlights that evidence is heavily concentrated within the awareness‐intent spectrum of behavior change and gets lean for outcomes situated within the intent‐action and the action‐habit formation spectrum of the behavior change continuum. Most of the evidence was concentrated on increasing awareness, knowledge, and building risk perception around SRH domains, however, fewer studies focused on strengthening the agency and self‐efficacy of individuals. Similarly, evidence on extrinsic factors—such as strengthening social and community norms, relationships, and household dynamics—that determine individual thought and action such as negotiation and life skills were also found to be less populated. Few studies explore the effectiveness of these interventions across diverse AGYW identities, like pregnant women and new mothers, sex workers, and people living with HIV, leading to limited understanding of the use of these interventions across multiple user segments including key influencers such as young men, partners, families, religious leaders, and community elders was relatively low. There is a need for better quality evidence that accounts for the diversity of experiences within these populations to understand what interventions work, for whom, and toward what outcome. Further, the evidence for use of digital and mass‐media tools remains poorly populated. Given the increasing penetration of these tools and growing media literacy on one end, with widening gender‐based gaps on the other, it is imperative to gather more high‐quality evidence on their effectiveness. Timely evidence generation can help leverage these platforms appropriately and enable intervention designs that are responsive to changing communication ecologies of AGYW. SBCC can play a critical role in helping researchers meaningfully engage and collaborate with communities as equal stakeholders, however, this remains poorly evidenced and calls for investigation and investment. A full list of abbreviations and acronyms are available in Supporting Information: Appendix F

Reports included in the synthesis.

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CHW cadres referred to in this paper.

CHW cadres referred to in this paper.</p