WHO NTEP Technical Support Network, Kerala, India.
State TB Officer, Kerala, India.
BMC Health Serv Res. 2022 Jan 2;22(1):2. doi: 10.1186/s12913-021-07342-y.
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.
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.
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.
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.
印度超过一半的结核病患者在私营部门寻求治疗。国家结核病规划（NTP）在过去 20 年中试图改善公私部门之间的合作，但除了在一些创新试点中取得了一些成效外，并没有成功。私营部门结核病消除系统（STEPS）于 2019 年应运而生，旨在确保所有到达私营部门的患者都能获得结核病护理标准。我们对 STEPS 进行了正式评估，以判断该模式在实现其结果方面的成功程度，并为在该国其他地区推广该模式提供信息。
成立了一个由所有相关利益攸关方组成的评估小组。制定了 STEPS 模型的逻辑框架。评估重点是（i）过程——活动是否按计划进行，以及（ii）近期结果——护理质量的改善和结核病监测系统的加强。我们（i）通过电话访谈 57 名结核病患者，对 30 个随机选择的 STEPS 中心进行了基础设施和流程评估（ii）从管理信息系统（iii）分析了 3 年来的患者护理质量指标（iii）对 33 名受益者和利益攸关方进行了深入访谈，以了解他们对 STEPS 的满意度和预期收益（iv）从 NTEP、私营医院和患者的角度对干预措施进行了成本分析。
评估结果表明，STEPS 是所有利益攸关方都能接受的模式。深度访谈结果表明，所有患者对所接受的服务都感到满意。NTEP 管理信息系统中的数据与医院记录和患者提供的信息一致。从私营部门报告的经微生物学证实的诊断的结核病患者比例从 2018 年的 25%提高到 2020 年的 38%，以及记录的治疗成功率从 2018 年队列的 33%提高到 2019 年队列的 88%，可以看出私营医院诊断的结核病患者的结核病护理质量指标有所改善。每增加一个治疗成功的额外患者的额外方案成本（扣除患者权益费用）估计为 67 美元。一家医院每年诊断 100 名结核病患者，实施 STEPS 的额外方案费用（扣除患者权益费用）估计为 573 美元，而医院的额外最低回报估计为 1145 美元。
评估结果证实，STEPS 是一种低成本、以患者为中心的策略。STEPS 成功地解决了私营部门寻求治疗的患者护理质量方面的差距，并确保服务符合结核病护理标准。STEPS 可以在类似环境中推广。
