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Changing epidelniological patterns and the advent of new rapid diagnostic technologies and therapies have created considerable uncertainty for providers working in HIV. In India, the demand for HIV care is increasingly being met by private practitioners (PPs), yet little is known about how they deal with the challenges of managing HIV patients. To explore HIV management practices in the private medical sector, a survey was conducted with 215 PPs in Pune, India, followed by in-depth interviews focusing on the social context of practice among a sub-set of 27 PPs. Drawing primarily on interview data, this paper illustrates a number of uncertainties that underlie the reported actions of providers in a competitive medical market. PPs perceive HIV as a 'new' and challenging disease for which they lack adequate knowledge and skills. Combined with the perceived high cost and complexity of antiretroviral treatment, preconceptions about HIV patients' social, financial and mental capacity lead to highly individualistic management practices. While these fall short of clinical 'best practice' guidelines, they reflect adaptive responses to the wider uncertainties surrounding HIV care in urban India. By highlighting contextual issues in PPs' management of HIV patients, the paper suggests the need to explicitly acknowledge the social, moral and economic bases of uncertainty beyond the clinical setting. Keywords. Private medical sector; Private providers: HIV/AIDS: Uncertainty: India

Abstract Background India's Revised National Tuberculosis Control Programme (RNTCP) is deemed highly successful in terms of detection and cure rates. However, some patients experience delays in accessing diagnosis and treatment. Patients falling between the 96th and 100th percentiles for these access indicators are often ignored as atypical 'outliers' when assessing programme performance. They may, however, provide clues to understanding why some patients never reach the programme. This paper examines the underlying vulnerabilities of patients with extreme values for delays in accessing the RNTCP in Mumbai city, India. Methods We conducted a cross-sectional study with 266 new sputum positive patients registered with the RNTCP in Mumbai. Patients were classified as 'outliers' if patient, provider and system delays were beyond the 95th percentile for the respective variable. Case profiles of 'outliers' for patient, provider and system delays were examined and compared with the rest of the sample to identify key factors responsible for delays. Results Forty-two patients were 'outliers' on one or more of the delay variables. All 'outliers' had a significantly lower per capita income than the remaining sample. The lack of economic resources was compounded by social, structural and environmental vulnerabilities. Longer patient delays were related to patients' perception of symptoms as non-serious. Provider delays were incurred as a result of private providers' failure to respond to tuberculosis in a timely manner. Diagnostic and treatment delays were minimal, however, analysis of the 'outliers' revealed the importance of social support in enabling access to the programme. Conclusion A proxy for those who fail to reach the programme, these case profiles highlight unique vulnerabilities that need innovative approaches by the RNTCP. The focus on 'outliers' provides a less resource- and time-intensive alternative to community-based studies for understanding the barriers to reaching public health programmes.

Background: Globally, Public-Private Mix (PPM) models of service delivery are recommended as a strategy for improving tuberculosis (TB) control. Several models of PPM-DOTS have been initiated under the Revised National TB Control Programme (RNTCP) in India, but scaling up and sustaining successful projects has remained a challenge., Aim: This paper examines factors accounting for the sustainability of a PPM-DOTS initiated in 1998 in Pimpri Chinchwad (PC), a city in Maharashtra, India., Methods: A two-year intervention research project documented the workings of the PPM-DOTS programme. This paper draws on in-depth interviews with programme officers and staff, and semi-structured interviews with private practitioners (PP) practising in the study area., Results: PPM-DOTS was originally introduced in PC, in order to increase access to DOTS. Over the years it has become an integral part of the RNTCP. Multiple approaches were employed to involve and sustain private providers' participation in PPM-DOTS. Systems were developed for supervision and monitoring DOTS in the private sector. Systematic use of operations research and successful mobilisation of available local resources helped set future direction for expanding and strengthening the PPM. The private sector's contribution to case detection and treatment success has increased, however ensuring referrals of TB suspects from all private providers continues to present a challenge., Conclusion: PPM-DOTS in PC is one of the few Indian models implemented as envisaged by global and national policy makers. Its successful operation for over a decade reiterates the importance of public sector initiative and leadership and makes it an interesting case for study and replication.

Background: The private medical sector is an important source of healthcare in India. Increasingly, concerns have been raised about its role in the care of patients with HIV/AIDS. Evidence about private practitioners' existing management practices will help to create policies addressing this sector., Methods: A central urban area of Pune city was selected for its high density of healthcare facilities. Private practitioners in the area were interviewed using a structured interview schedule. Based on a 1-year recall period, the schedule covered different aspects of the practitioners' HIV/AIDS management practices including diagnosis, treatment and referral., Results: Of the 215 practitioners interviewed, 66% had tested and diagnosed HIV infection. Fifty-four per cent had been consulted by HIV-infected clients 'shopping' for alternative diagnoses or treatment. Overall, 75% of the respondents had been consulted by HIV-infected clients for treatment. Of these, 14% had prescribed antiretroviral drugs, sometimes without adequate knowledge of the guidelines for their use. Other supportive and symptomatic treatments were also frequently prescribed. Private practitioners commonly referred HIV-infected clients for management to other private doctors, or to public hospitals. There were variations in respondents' practices by sex and system of medicine., Conclusion: Private practitioners are actively involved in diagnosing and managing patients with HIV/AIDS. Some of their management practices are inappropriate and need to be remedied. There are also concerns about gaps in the continuity of care of HIV-infected persons, for which networks between providers need to be strengthened. Public-private partnerships must be created to improve the flow of information to private practitioners, and Include them in the national health framework.

The Revised National TB Control Programme (RNTCP) in India has made definite progress over the last 2 years and given a boost to global DOTS expansion. The Private Practitioners (PPs) involved in Public-Private Mix (PPM) in India's RNTCP are the first point of contact for more than 2/3rds of TB symptomatics. The vital components of PPM approach are supervision and monitoring of diagnosis of referred cases from PPs, functioning of private laboratories, registration of confirmed cases, treatment with DOT and documentation. The most important contribution of some of the PPM projects has been the creation of a link in the form of a referral system between the private and public sectors. PPM can contribute positively to the performance of RNTCP. RNTCP should be seen as the first step towards an exciting direction in engaging private sector in public health programmes.