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An Innovative Intervention in Indian Private Sector: Initiative for Promoting Affordable Quality TB Tests (IPAQT)

29 March 2014 Dr. Manjot Kaur (Clinton Health Access Initiative)

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The need for a private sector focused initiative

IPAQT Background

| 3 SOURCE: 1. RNTCP TB India Report 2013: Annual TB Incidence (India) is 2.3 million, prevalence is 3.1 million

India has the world’s largest TB burden; more than half are managed in the private sector….

Total TB patients in the world (2011) = 11 million

India 25%

Rest of the World 75%

Public sector,

40%

Private sector,

60%

India has ~1.5 million TB patients under treatment in the public sector alone; the full extent of the disease burden in the private sector is unknown

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The country’s large private sector plays a key role in all areas of healthcare

57%

80%

80%

Hospitalised Care

Outpatient Care

Doctors

Share of Private Sector in Indian Healthcare Market1

India has the one of the largest private healthcare sectors in the world. Implications include -

•72% of healthcare expenditure is out of pocket1

•Debilitating effects on the poor – liquidation of assets; indebtedness (40% of hospitalized & 2% in the country every year end up BPL1

SOURCE: 1. 60th NSS-2005, Venkat Raman et al

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…especially in TB, where the majority of the TB patients start their journey of diagnosis and treatment in the private sector

SOURCE: 1. Kapoor SK et al. PLoS ONE 2012

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CHAI chose to focus on diagnostics because timely and accurate diagnosis is key to disease control

Impact of various interventions on TB cases reduction in India1

Most effective intervention: Reduction in number of diagnostic encounters

SOURCE: 1. Goodchild et al. (2010). The health and economic burden of tuberculosis in India

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Ex-factory price (x)

Taxes & transport charges (1.3x)

Distributor margins (1.9x)

Reference lab margins (2.5x)

Franchisee lab margins (2.9x)

Channel margins (3.3x)

Patient price

Too many intermediaries in the value chain.. ..mean high patient prices

Avg monthly HH income of TB patients

₹ 3000

Costs of Quality Assured Diagnostics in the private diagnostics market are very high

₹5,000

₹4,000

₹3,500

₹100

MGIT + DST

GeneXpert

Hain

Smear

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In June 2012, the GoI banned the serology, and an opportunity to influence the private sector emerged

Ban on serology by GoI Requirement for a “replacement test”

Serology 52%

PCR, 10%

Culture, 10%

TB-Gold, 2%

Smear microscopy,

26%

Hain LPA, 0%

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CHAI worked out a solution to provide WHO-endorsed tests at lower costs to the private labs

Goal: Improving public health

Diagnostics Manufacturers Private Laboratories

RNTCP and NGOs

Goal: Maximizing ROI Goal: Maximizing ROI

Not eligible for lower public sector

pricing

Unable to individually negotiate

competitive prices with

manufacturers

Unable to generate volumes and tap

the huge potential of the Indian

private market

TB Programme and NGOs eligible for the public sector pricing

CH

AL

LE

NG

E

SO

LU

TIO

N

IPAQT structure

Private labs

CHAI

Higher volumes

Access to quality tests

at lower price

Lower Investment in

machines as well as

reagents/cartridges

RNTCP

Access to affordable

quality diagnostics

Linkage to better

treatment through

public sector

Access to data on

positive cases in the

private sector for

treatment follow-up

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Patient

Hain GenoType

IPAQT is aimed at creating a win-win-win for all stakeholders

The project is led by a Governing Council which regulate the activities of IPAQT labs, and is a think tank for future plans

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The governing council consists of opinion leaders from academia, private labs, civil society and NGOs, and collectively takes decisions on issues like criteria for including labs in IPAQT, actions to take against that do not adhere to the guiding principles, etc.

Governing council members

• Dr Nalini Krishnan – REACH

• Dr Madhukar Pai – McGill University

• Dr Sarabjit Chadha – UNION

• Mr Harkesh Dabas – Country Director, CHAI

• (Hony) Brig. Dr Arvind Lal, Padma Shri – Dr Lal Path Labs

• Dr Sanjeev Chaudhary – SRL

• Ms. Ameera Shah (Co-Chair) – Metropolis

• Dr Navin Dang – Dr Dang’s Lab

Use of only high-quality TB tests

Notification of TB cases to RNTCP

All member labs to

undergo periodic

external quality

assurance (EQA)

Only accredited labs

can join

Consortium labs

notify all positive

cases to National TB

Program to enable

Option of free

treatment/follow-up

Mechanisms to track

treatment adherence

IPAQT Guiding

Principles

Increasing access to early and accurate diagnosis

Patients are charged at

or below a ‘Ceiling Price’

₹4,000 ₹3,500

₹1,100

₹2,000 ₹1,600

₹900

GX Hain LPA MGIT

Market price

IPAQT price

Any private lab can join IPAQT if they agree to follow the key guiding principles which are entrenched in IPAQT objectives

IPAQT objective

GX Hain

Number of labs 50 19

Lowest price 1500 1400

No. of tests (till Feb’14) 22,210 13,278

..and over 40 installed bases 64 member labs

(+ 70 prospective labs)

Member labs include– • 5 of the 6 national lab chains • 20 Hospitals • 25 Regional chains • 12 Stand-alone labs

Not Available

500

13,278

22,210

Hain LPA GeneXpert

Pre-IPAQT Post-IPAQT

IPAQT has made significant progress since its inception in March 2013

1. Dr Dang’s Diagnostic Labs, Delhi

2. Dr Suri Lab Pvt Ltd , Delhi

3. Advance Labs, Surat

4. Microcare Labs, Surat

5. Speciality Microtech, Ahmedabad

6. Supratech Micropath Laboratory & Research Institute, Ahmedabad

7. Greencross Pathology, Ahmedabad

8. Dr Bhatt Pathology Laboratory, Rajkot

9. Sanjeevani Pathology , Rajkot

10. Dr Ahuja Pathology Lab, Dehradun

11. Gian Pathology And Xray, Kanpur

12. Medicos Center, Chandigarh

13. Dr Gajendra Yadav Pathology Laboratory, Rewari

14. Scientific Pathology & Imaging, Agra

15. Subharti Medical College, Meerut

16. Central Diagnostics Oncotech, Indore Sampoorna Sodani, Indore

South

1. RDT Hospital , Bathlapalli

2. Blue Peter Health and Research Centre, Hyderabad

3. Vijaya Diagnostic Center , Hyderabad

4. Yashoda Hospital

5. Bharat Speciality Lab, Chennai

6. Hitech Diagnostics, Chennai

7. SRM Hospital, Chennai

8. YR Gaitonde Centre, Chennai

9. Microbiological Laboratory, Coimbatore

10. PSG Hospitals, Coimbatore

11. Bioline Laboratories, Coimbatore

12. Anand Labs, Bangalore

13. St John’s Research Institute, Bangalore

14. KMC Manipal

15. KMC, Mangalore

16. KS Hegde medical college

17. Manipal Hospitals

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These tests can be accessed at nearly 4000 collection centers across India

North

1. Dr Dang’s Diagnostic Labs, Delhi

2. Dr Suri Lab Pvt Ltd , Delhi

National Chains

1. Dr. Lal Path Labs

2. SRL Diagnostics

3. Metropolis

4. Vimta Labs

5. Quest Diagnostics

East

1. AMRI Hospitals, Kolkata

2. Boyd's Pathology , Bhagalpur

3. Central Diagnostics, Patna

4. DRS. Tribedi & Roy, Kolkata

5. Geeta Molecular, Darbhanga

6. Maurya Labs , Purnia

7. Nazareth Hospitals, Shillong

8. Probe Diagnostics, Kolkata

9. Scientific Clinical Research Lab, Kolkata

10. Sen Labs, Patna

11. Sharma Diagnostics, Bhagalpur

12. Woodland Hospitals, Shillong

West

1. Dhruv Pathology , Nagpur

2. Dr Bhide’s Laboratory Services, Mumbai

3. Dr. Ajay Shah Laboratory, Mumbai

4. Hinduja Hospital , Mumbai

5. Kokilaben Dhirubhai Hospital, Mumbai

6. MGM Kamothe Medical College, Mumbai

7. Dr Avinash Phadke’s Labs, Mumbai

8. Suburban Diagnostics, Mumbai

9. Tata Memorial Hospital, Mumbai

10. Holy Spirit Hospital, Mumbai

CHALLENGES, FUTURE

PLANS AND TIMELINES

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There are several challenges in making WHO-endorsed diagnostics the preferred choice in the private sector

SOURCE: 1.TB Diagnostic in India’s private sector survey : Conducted in Feb 20132. 2Information from IPAQT labs

Low provider awareness levels

A survey conducted by CHAI reveals that ~ 85

% of the providers are not aware about

molecular tests

Providers ordering IGRA based test strongly

believe that these tests are valid for diagnosing

active TB

91

82

63

42

40

25

16

13

0 20 40 60 80 100

Chest X-Ray

Smear Microscopy

Tuberculin Skin Test

TB Culture

TB Serological Tests

TB Drug Susceptibility

TB NAAT

TB Gold

TB tests awareness among providers

Figures in percentages

Base: All providers = 1244

Low interest on part of labs – market dynamics

Private labs and collection centers make higher

margins on sub-optimal tests such as IGRAs and

in-house PCRs

$4

$11

$3

$8

$2

$4

$2

$4

Reference lab Collection center

TB Gold In-House PCR GeneXpert Hain LPA

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Increasing

Access to WHO-

endorsed tests

Linkage with

Treatment

IPAQT’s plans for the future are linked to two main areas

Increase availability of quality assured tests by increasing the the number of labs participating in IPAQT

Increasing awareness of value of WHO endorsed tests among privately practising doctors:

• Plans for 1-2 CMEs a month till end of 2014 • 12 CMEs conducted since November 2013 • Dr. Madhukar Pai spoke about IPAQT in his presentation at the IAMM conference in Hyderabad in November 2013

Plans to develop a patient notification mechanism at all IPAQT labs –

through collaboration with referring physicians

Plans to put in place a mechanism to record and track patient data through a team of “field agents” placed at laboratories; to be piloted in 5 cities – Delhi, Mumbai, Patna, Coimbatore, Lucknow

Pilot to start in May 2014

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Lowering the barriers by on-ground presence – the FA Project

Private doctors in the city Professional Groups – IMA, NCCP,

etc.

IPAQT Field

Agent

TB

suspects/patients

IPAQT LAB 1

IPAQT LAB 2

IPAQT LAB 3

IPAQT

Laboratories

Encourages

data recording –

patient

information and

transfer to

“Nikshay plus”

Weekly data

collection on

positive TB and

MDR cases

Drives awareness for

WHO approved tests

through meetings,

presentations, CHAI

supported CMEs

District TB

Officer

Notification

of TB+ and

MDR cases

District DOTS field technicians

Follow-up/

treatment

tracking

Fa

cil

ita

te n

oti

fic

ati

on

R

ais

e p

rovid

er

aw

are

ne

ss

Small field teams of “IPAQT Specialists” (or “Field Agents”) with the objective to work with IPAQT partner labs to -

Promote awareness of tests in their provider network through regular in-clinic visits

Facilitate notification process for them by helping in data management

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Thank You Thank you

Please visit www.ipaqt.org for more information