A majority of patients with tuberculosis (TB) in India are diagnosed and treated in the private sector. Yet, most private providers do not use most recent WHO-endorsed microbiological tests such as liquid cultures, line probe assays and Xpert MTB/RIF due to a combination of factors such as lack of awareness, misaligned incentives and high prices that are unaffordable for patients. We designed a market-based approach to transform a high-price, low-volume market equilibrium into a low-price, high-volume equilibrium to improve the uptake of these tests. Toward this end, a non-profit consortium of private laboratories, called Initiative for Promoting Affordable and Quality Tuberculosis Tests (IPAQT) was formed in India in March 2013. It negotiated lower pricing on equipment and reagents with manufacturers, closer to that offered to the public sector. In return, IPAQT assured that this discount was passed on to patients, who typically paid for these tests out of their pockets, through an informally agreed on retail ceiling price. IPAQT also invested in demand generation activities that complemented the supply-side effort. IPAQT membership grew from 56 laboratories in 2013 to 211 in 2018. During this period, the initiative resulted in a 10-fold increase in the uptake of Xpert and a 30%–50% reduction in price. This initiative is planned to be expanded to other South Asian countries with similar TB epidemic and private market structure and dynamics. However, long-term sustainability of the initiative would require developing more cost-effective marketing activities and integration with broader private sector engagement agenda of the national TB programme.
- health systems
- public health
- intervention study
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PD and MP are joint senior authors.
Handling editor Seye Abimbola
PD and MP contributed equally.
Contributors HD, PS, MP and PD oversaw the development and the implementation of the intervention. MS, APal, SS, LN, KC, PM, APar, RS, MC, RK, MK, CO and NP participated in the development and management of the intervention, including collection of data. SK, PS, PD and MP provided critical inputs on the development and intervention of the intervention and data analysis. SD provided critical inputs on the development and intervention of the intervention and data analysis, analysed the data, wrote the manuscript and made critical reviews and edits. All authors critically reviewed the manuscript. All authors agreed on the results and findings, attested to their correctness and agreed to submit the manuscript.
Funding SD’s research was funded by the Bill and Melinda Gates Foundation and the Clinton Health Access Initiative. MP’s research is supported by the Bill and Melinda Gates Foundation and he was a recipient of a Canada Research Chair award by the Canadian Institutes of Health Research.
Competing interests MP has previously served as a consultant to the Bill and Melinda Gates Foundation. He was involved in creating Initiative for Promoting Affordable and Quality Tuberculosis Tests (IPAQT) and also serves on the governing council of IPAQT. PD and PS were previously employed at the Bill and Melinda Gates Foundation and were involved in creating and funding IPAQT. SD has served as a consultant to the Bill and Melinda Gates Foundation. KC, PM, AP, RS, RK and MK were previously employed at the Clinton Health Access Initiative and were involved in the implementation of IPAQT.
Patient consent for publication Not required.
Provenance and peer review Not commissioned; externally peer reviewed.
Data availability statement Proprietary data regarding sales and pricing were used for analysis. These data cannot be made available publicly.