Sociology of Health & Illness Vol. 36 No. 6 2014 ISSN 0141-9889, pp. 917–931 doi: 10.1111/1467-9566.12125

Organisational innovation and control practices: the case of public–private mix in tuberculosis control in India Nora Engel1 and Harro van Lente2 1

Department of Health, Ethics and Society/School for Public Health and Primary Care, Faculty of Health, Medicine and Life Sciences, Maastricht University, The Netherlands 2 Copernicus Institute of Sustainable Development, Faculty of Geosciences, Utrecht University

Abstract

Partnerships between public and private healthcare providers are often seen as an important way to improve health care in resource-constrained settings. Despite the reconfirmed policy support for including private providers into public tuberculosis control in India, the public–private mix (PPM) activities continue to face apprehension at local implementation sites. This article investigates the causes for those difficulties by examining PPM initiatives as cases of organisational innovation. It examines findings from semi-structured interviews, observations and document analyses in India around three different PPM models and the attempts of innovating and scaling up. The results reveal that in PPM initiatives underlying problem definitions and different control practices, including supervision, standardisation and culture, continue to clash and ultimately hinder the scaling up of PPM. Successful PPM initiatives require organisational control practices which are rooted in different professions to be bridged. This entails difficult balancing acts between innovation and control. The innovators handle those differently, based on their own ideas of the problem that PPM should address and their own control practices. We offer new perspectives on why collaboration is so difficult and show a possible way to mitigate the established apprehensions between professions in order to make organisational innovations, such as PPM, sustainable and scalable.

Keywords: tuberculosis, public–private mix, India, innovation, control Introduction Partnerships between public and private healthcare providers are often seen as a way to improve health care in low-income settings. The term public–private partnerships (PPPs) refers to a joint effort between a private and a not-for-profit organisation aimed at the creation of social value (Reich 2000). These partnerships range from global governance models (Buse and Harmer 2007) to product development partnerships (De Pinho Campos et al. 2011), and different local service delivery approaches whereby public authority generally oversees the activity (Raman and Bj€ orkmann 2009). The evidence of functioning partnerships, their feasibility and their positive impact on the quality and utilisation of healthcare services is not yet conclusive (Patouillard et al. 2007, Peters et al. 2004) and has been mostly focused on contracting and © 2013 The Authors Sociology of Health & Illness © 2013 Foundation for the Sociology of Health & Illness/John Wiley & Sons Ltd. Published by John Wiley & Sons Ltd., 9600 Garsington Road, Oxford OX4 2DQ, UK and 350 Main Street, Maiden, MA 02148, USA

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social franchising (Koehlmoos et al. 2009, Palmer et al. 2006). What is agreed is that private providers, including non-government organisations (NGOs), play a significant role in the healthcare systems of many low-income countries and that their activities should be aligned with national and global public health objectives (Brugha and Zwi 2002, Hanson et al. 2008, Mills et al. 2002). The latter is also relevant to coordinate tuberculosis (TB) control and for nearly two decades efforts have been made to engage the private medical sector and civil society as partners of public TB control programmes. Under the name of a public–private mix (PPM) these partnership initiatives aim to strengthen treatment efforts through referral systems between the public and private providers, to reach out to more patients and to provide standardised diagnoses and treatment (Stop TB Department 2006). The latter is a key element in preventing the emergence of resistance to anti-TB drugs, particularly in countries such as India, where private practitioners provide health care to most of the population (both poor and rich patients alike) (Agarwal et al. 2005). These private providers range from highly qualified specialists to unqualified practitioners and local healers (De Costa, Johansson, and Diwan 2008). The diagnosis and treatment of TB in the private sector vary largely and are often inadequate, unregulated or insufficient, leading to failure cases and ultimately breeding drug resistance (Ecks and Harper 2011, Udwadia et al. 2010, Uplekar and Rangan 1993). It is thus no surprise that some of the earliest PPM initiatives for TB started to emerge from India in 1995, which fostered the development of global World Health Organization ([WHO] 2001) and national PPM guidelines (Central TB Division 2005a, 2005b, Central TB Division 2008). However, implementing and scaling up PPM remains a challenge, because collaboration is hampered by apprehensions among the different professions (De Costa and Diwan 2007, Uplekar, Pathania, and Raviglione 2001). Explanations offered in the literature on PPM and the role of the private sector in India, more generally, point to a lack of willingness to interact and conflicting perceptions of collaboration among healthcare providers, such as different views on the importance of PPM, a mutual lack of trust and a lack of belief that there is a common ground (De Costa, Johansson, and Diwan 2008, Uplekar, Pathania, and Raviglione 2001). Most existing studies or reports on PPM focus on the evaluation of performance and cost-effectiveness of PPM (De Costa, Johansson, and Diwan 2008, Dewan et al. 2006, Floyd et al. 2006, Kumar et al. 2005, Lal et al. 2011, Lonnroth et al. 2004, Murthy et al. 2001, Pantoja et al. 2009, Rangan et al. 2003, Uplekar 2003, WHO 2004). While it is largely acknowledged that the evidence on the effectiveness of PPM approaches on which the WHO′s PPM policy is based is rather weak (Mahendradhata et al. 2007), these studies do not pay enough attention to the innovative character of PPM activities. To understand these implementation problems, we investigated India’s PPM efforts as a case of innovation and control. In order to do so, we focused on the PPM as an innovation in the organisational set-up of TB control. Based on qualitative fieldwork in India, we analysed the processes through which PPM initiatives are designed. How are PPM initiatives developed? How do they make their way through existing control practices? And what can we learn from that about scaling up of PPM? We show how problem definitions, control practices and professional boundaries may clash and affect the overall efforts to control TB. The basic argument is that practices of innovation and control in PPM provide important conditions of the sustainability of PPM initiatives. Our analysis offers new perspectives on why collaboration is so difficult and shows a possible way out of established ways of blaming and apprehension among the different professions. These insights are timely, because for 2012–2017 the Revised National Tuberculosis Control Programme (RNTCP); the Indian TB programme, has set the ambitious plan to provide universal access to quality TB diagnosis and treatment for the entire population (Central TB Division 2011). This requires, among others, greater financial resources to be allocated to TB, improved © 2013 The Authors Sociology of Health & Illness © 2013 Foundation for the Sociology of Health & Illness/John Wiley & Sons Ltd

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diagnostics and a strong involvement of the private sector (Pai 2011). The insights will also be important for PPM initiatives across different geographical contexts and for disease control in general.

Theory: organisational innovations, problem definitions and control practices There is widespread agreement that innovation in health care goes beyond technological capacity and innovation diffusion (Bonair et al. 1989), but also includes social aspects of health care, managerial systems, governance, processes of delivery and social and institutional mechanisms to encourage outreach (Dowdeswell et al. 2006, Faulkner 2009, Lemieux-Charles et al. 2002). Innovation in TB control is thus more than technological innovation in drugs, diagnostics and vaccines and encompasses delivery mechanisms, service processes, institutions, the organisational set-up and treatment regimes and concepts (Consoli and Ramlogan 2008). Accordingly, we use a broad definition of innovation as the change when new knowledge is introduced (new to the respective actor group). The focus of this article is on innovation in organisational aspects of TB control which involves, for example, new or altered ways of organising activities or healthcare personnel internally or with external supplier organisations, interactions among healthcare providers and the organisation of supplies. The literature in innovation studies has mainly focused on understanding particular innovation systems with national, sectoral or technological boundaries (Edquist 1997, Metcalfe and Ramlogan 2008, Nelson 2001). These authors have thereby neglected individual entrepreneurs and the actual dynamics in innovation systems, such as how these systems function or the inherent power relations between the actors in the system (Hekkert et al. 2007). Science and technology scholars highlight the fact that actors often use very different definitions of problems, which can guide the direction of innovation processes, although these authors are mainly focused on technological innovation (Bijker 1995, Borup et al. 2006, Latour 1987, van Lente 2010). The medical sociology and anthropology literature confirms the importance of problem definitions. Studies of the social construction of diseases (Kreimer and Zabala 2007, Nicholson-Crotty and Nicholson-Crotty 2004), on framing diseases (Aronowitz 2008), social representation (Flick 2000) and the role of metaphors (Sontag 1978, Wallis and Nerlich 2005) show that labelling bodily processes as sickness and framing diseases (problems) in a specific way is a social process, shaped by the power and interests of the shapers. We show that definitions of problem clash, contradict or challenge each other and therefore influence organisational innovation as well. A further concept in our analysis is the notion of control. The main goal of infectious disease control is to control and orchestrate a variety of actors involved. This control work is ubiquitous and targeted at, for example, TB bacteria, but also at healthcare providers, patients’ adherence to treatment, control of data and diagnostic and treatment processes. The healthcare literature discusses control practices in terms of management (Khatri, Brown, and Hicks 2009, Trenholm and Ferlie 2013, Witte 1993). A control-based management style assumes that actors need continuous control, reward and guidance, while a commitment-based management style fosters the initiative and self-direction of employees (Khatri et al. 2009). In this article we do not use a dichotomy of control versus commitment, but we use instead the notion of control practices. Organisational control practices have been classified as firstorder (direct supervision), second-order (standardisation) and third-order controls (ideology/ culture) (adapted from literature on improvisation in organisations [Dougherty 1996, Kamoche et al. 2002]). © 2013 The Authors Sociology of Health & Illness © 2013 Foundation for the Sociology of Health & Illness/John Wiley & Sons Ltd

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Methodology The research approach was qualitative and exploratory, which is useful for showing the entrenched, contextual processes of innovation. We adopted a research heuristic commonly applied in science and technology studies that does not make any a priori distinction between disciplines, expertise or actors. What mattered, instead, was to trace actors and actions involved across different social worlds (Latour 1987). The social worlds that are engaged with TB control in India range from those of global health policy, the TB programme, patients and practitioners and the laboratories. A network of informants across the country was built up using a snowballing technique and actors and actions were followed (Latour 1987). The data were collected as part of a larger project on innovation dynamics in TB control in India by the first author and took place in two rounds from December 2007 to April 2008 and from November 2008 to April 2009 in Hyderabad, Krishna and Warangal District (Andhra Pradesh), Ahmedabad, Pune, Mumbai, Delhi, Chennai and Bangalore. Data collection included 101 semi-structured interviews (with public health experts, policymakers, scientists, scholars, physicians, medical staff, private practitioners, community volunteers, patients and members of civil society and the international donor community); observations at hospitals, health centres, research institutes, community projects, patient homes and treatment sites and documentary research (government documents, conference proceedings, research articles, news items and the Internet). The interviews lasted on average 1.5 hours and were guided by a general topic list which focused on the description of innovation processes (including the origins of the innovations, the key actors and their interactions, processes and critical events, scaling up and crucial factors influencing innovative activity), problem definitions of actors involved (including their understandings and perspectives on the disease, the patients and the Indian health system) and practices of control. We paid attention to practices by examining daily work, routines, understandings of control and ideal views on TB control. The interviews were adjusted to the background of the interviewee, audio recorded with the permission of the informant and either transcribed verbatim or transformed to text in a draft (Gibbs 2007). Verbatim transcription was done for most of the interviews, based on importance of an interview in answering the research questions and of those interviews where the notes taken were insufficient. Translators were rarely necessary, since most health workers spoke English fluently. At the subdistrict level and in patients’ interviews, a health worker or non-governmental organisation (NGO) staff member translated. This took place ad hoc, with the advantage that the interviewee did not experience it as a formal interview situation and was often familiar with the person who was translating. While the entire corpus of empirical material was used to inform the context of the study, the theoretical lens on organisational innovation led to focusing on the interviews and material that address PPM activities and three different cases of early PPM models that were initiated by different actor groups. The software Atlas-ti was used to support the data analysis and break down the data into manageable chunks (Gibbs 2007, Rubin and Rubin 2005). An initial coding scheme was tested on a handful of varied interviews and further refined (Rubin and Rubin 2005). The analysis was supported by a research strategy of building theory from case studies (Eisenhardt and Graebner 2007) and is based on writing thick descriptions, examining patterns and linkages between themes and codes and several cross-case searching tactics (by an analysis different understandings of concepts, iconic events or rituals; the comparison of selected pairs of cases and combing data by source) (Eisenhardt and Graebner 2007, Rubin and Rubin 2005). Fieldwork reports allowed several analytical iterations and an overlap of data © 2013 The Authors Sociology of Health & Illness © 2013 Foundation for the Sociology of Health & Illness/John Wiley & Sons Ltd

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collection and preliminary data analysis. Different data sources were referred to in order to validate findings, cross-check and triangulate the data.

Results In this section we discuss three early PPM initiatives and the resulting efforts to scale up PPM. The results are presented in two steps: we will first investigate the processes of (i) organisational innovation, including different problem definitions for each of the three PPM initiatives and subsequently (ii) examine different control practices that have been identified across all PPM initiatives. PPM: an organisational innovation Firstly, we will discuss three of the early PPM initiatives by different actor groups. They were chosen because they represent and propose different organisational models for PPM (referral between RNTCP and private practitioners, the NGO as intermediary, and sensitisation through professional associations) and illustrate different actor positions in the dynamics: the Mahaveer model by a private practitioner in Hyderabad, the Mumbai model by an NGO and the Kerala model by a professional association. We examine how the problem of PPM was defined and what organisational innovations were derived, influenced by the different control practices of the main innovators. The PPM model by the team at Mahaveer Hospital, a private, non-profit trust hospital in Hyderabad, implies a basic process of referral. If a private practitioner refers a patient to the public health facility, the RNTCP staff diagnoses and initiates treatment, keeps the private practitioner informed and always refers the patient back to the private practitioner with an acknowledgement letter and the assurance that the patient can continue to take directly observed treatment, short-course (DOTS) (the WHO’s TB control strategy consisting of standardised treatment regimens of 6–8 months with direct observation of drug intake for at least the initial 2 months [WHO 2002]) under the private practitioner’s care (Murthy et al. 2001) (interview, private physician 2, Hyderabad, 24 November 2008). As the main physician emphasises, the most important contribution of PPM for the patient is convenience and for the private practitioner to be acknowledged and respected: [The] PP [private practitioner] is only [offering] a place wherein the person will come and consume it without transportation and loss of opportunities … We all just only said two points [to convince the PPs to participate]: refer the patients and we will refer them back. That’s the only thing. Acknowledgement letters. Every patient goes back with the acknowledgement letter. (Interview, private physician 2, Hyderabad, 9 March 2009) For the team at Mahaveer, the problem that PPM should address is defined as ignoring the patients’ psyche and not respecting the referral decisions of private practitioners, particularly slum doctors, who are often unqualified but are in many cases the first medical contact for poor TB patients. The Mahaveer team emphasise the need to establish respectful partnerships with all private practitioners, even if they are unqualified, and argue that this respect is sometimes neglected in PPM efforts by the TB programme. The main innovator is a private chest physician who is concerned with comprehensive lung care. He has always been close to patients and emphasises the importance of respecting private practitioners and their professional pride (interview, Hyderabad, 9 March 2009). RNTCP officers had initial apprehensions of the PPM model as developed at Mahaveer because of its involvement of unqualified © 2013 The Authors Sociology of Health & Illness © 2013 Foundation for the Sociology of Health & Illness/John Wiley & Sons Ltd

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practitioners. These unqualified practitioners predominate in poorer areas and, in general, see many more TB patients, because they are more accessible to the patients than qualified doctors do (because they live in the vicinity and have flexible opening hours, for example). From a programme officer’s perspective, involving unqualified practitioners would mean acknowledging their practices. Despite these apprehensions, the Mahaveer model managed to gain the attention of the WHO during the pilot project and was thereafter sponsored and supported by the UK Department for International Development and the WHO. This model became globally well-known and the leading physician of the Mahaveer PPM project travelled the world as a national and international PPM consultant for the WHO (Uplekar 2003). The Mumbai model emerged from PPM pilot projects between 2001 and 2005 in Mumbai run by Medecins sans Frontieres and Inter Aide, two international NGOs with national project offices. Here, an NGO with a civil society mandate acted as an intermediary between private practitioners and the TB programme (transporting sputum, tracing defaulters, supporting patients and sensitising private practitioners). One programme manager argues: Here [in Mumbai] a lot of PPs had been already sensitised [for PPM], but they found that referral did not sustain because they [the RNTCP staff] did not visit PPs often enough … NGO has to act as a middleman. The system cannot be left by itself; you have to be there. (Interview NGO programme manager 1, Mumbai, 19 December 2008). The team involved in the Mumbai model argues that an NGO acting as an interface is needed, because the PPM cannot sustain itself due to the lack of commitment by the TB programme staff. These arguments are linked to the NGO′s work in the community. NGOs often operate close to poor communities and are engaged in prevention, treatment and community education. The Mumbai model, thus, implies to offer support to the TB programme through an intermediary organisation based on the NGO′s connections and detailed knowledge of the community. The third model, piloted in Kerala in 2002/2003, was based on the sensitisation of private practitioners through the Indian Medical Association (IMA), a professional association of qualified allopaths mainly focused on lobbying for the interests of its members. An IMA official argues that the main problem that has to be solved to make TB control succeed is to convince private practitioners to follow the standard treatment by the TB programme because they attract the bulk of the patients (interview, IMA consultant 1, Delhi, 19 January 2009). As another IMA consultant puts it: ‘The government has a programme. The private practitioners have patients’ (Hyderabad, 25 February 2009). In order to bridge the two, deep-rooted tensions, rivalry and suspicion between providers and dependency on committed individuals need to be overcome (interview, IMA consultant 1, Delhi, 19 January 2009). As an institutional interface, IMA focuses on sensitising and motivating private practitioners to join the RNTCP and become DOTS providers, and subsequently training them. The efforts by the IMA are concentrated on allopathic practitioners registered with them and do not reach the often unqualified slum doctors and non-allopaths. If a private practitioner has agreed to become DOTS provider, it is left to the RNTCP and the private practitioner to make the PPM work. The Mumbai and the Mahaveer model were both further developed in Urban DOTS projects (2005–2008). These projects were supported by international donor funding (largely through the Global Fund to Fight Aids, TB and Malaria) and the project areas were enlarged to cover an entire city each. Both ended with no replication or further scaling up to the TB programme. Some of the insights gained in the Mumbai and Mahaveer model were used as inputs for revising the PPM guidelines in 2008 (Central TB Division 2008) (interviews: physician NGO 1, 18 December 2008; private physician 2, 9 March 2009; Hyderabad Urban DOTS, 2008). In January 2008 a 3-day consultation meeting was held by the Central TB Division with 60–70 © 2013 The Authors Sociology of Health & Illness © 2013 Foundation for the Sociology of Health & Illness/John Wiley & Sons Ltd

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participants, based on which the revised policy guidelines for involvement of private practitioners and NGOs were formulated. The meeting brought together for the first time a wide range of stakeholders (private and public) involved in TB control (RNTCP officers and staff, private practitioners’ representatives, experts from outside the programme and NGOs) (interviews: RNTCP consultant 2, Delhi, 15 January 2009; TB consultant WHO 1, Delhi, 14 January 2009). Yet not all innovators of the different PPM initiatives were present. Along with the revised guidelines, the Kerala model by IMA was given responsibility by the TB programme to carry PPM forward (WHO 2009). IMA advocates PPM among its members and provides training to states and district-level physicians (interview, physician NGO 1, Mumbai, 18 December 2009). In turn, the innovators of the Mumbai and Mahaveer model are sceptical as to whether IMA is able to take PPM forward, because IMA representatives do not reach the slum doctors, non-allopaths and the communities in which TB patients are living, but rather concentrate on better situated allopathic private practitioners. The team at Mahaveer is unhappy about how the initial ideas of PPM were taken up by the RNTCP and are being implemented in a top-down manner, by missing out the slum doctors, creating more bureaucratic barriers and ultimately missing again the psyche of the patient (interview, private physician 2, Hyderabad, 24 November 2008). Apart from the consultation meeting, there has been hardly any exchange among initial PPM initiatives. These actors knew vaguely about each other from the media, journal articles, NGO workers or RNTCP staff. Rarely, however, have opportunities been used or created to meet and exchange experiences and ideas. PPM: control through supervision, standards and culture PPM implies changes in all three different orders of organisational control. In this section we discuss how control through supervision, standards and culture is practiced by making use of the insights gained across the three different PPM initiatives. Firstly, different forms of supervision are practiced at various levels. The RNTCP, for example, makes use of the direct supervision of patients when they swallow their drugs. The DOTS provider ticks off boxes on the patient’s TB card for every dose swallowed. Healthcare workers try to locate and motivate patients who miss their treatment for more than three times. The RNTCP has set up a highly systematic reporting and recording structure, including a plethora of different forms and registers that allow the supervision of healthcare providers and staff as well as patients (these include the laboratory form for sputum examination, the tuberculosis treatment card, the patient’s identity card, the referral form for treatment, transfer form, mycobacteriology culture/ sensitivity test form, tuberculosis laboratory register, tuberculosis register, peripheral health institution-level supervisory register, referral for treatment register, stock register and reconstitution register (Central TB Division 2005c). Among the private medical sector there is generally hardly any form of patient supervision. Due to the sector’s unregulated nature, other forms of supervision, such as legal obligations, reporting and notification practices, are applied less strictly in the private medical sector in India than in the public sector or in the private sector in many other countries. In PPM much of the direct supervision of patients and healthcare workers in administering DOTS is transferred to external partners. This requires trust, openness and often changes in the attitudes of the RNTCP staff towards their external partners, particularly because the RNTCP staff are also evaluated on the data co-generated by these partners. Giving up control is challenging, in light of the tendency to blame each other for not providing good care s. The RNTCP staff perceives the private practitioners as being untrustworthy, interested only in making profit and being unsupportive of public health goals. Private practitioners and patients, on the other hand, have a negative image of the quality of care in the public sector. In some © 2013 The Authors Sociology of Health & Illness © 2013 Foundation for the Sociology of Health & Illness/John Wiley & Sons Ltd

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cases, NGOs engaged in a PPM initiative have pointed out problems or malpractice in a particular TB district by the RNTCP. This can cause resistance among the RNTCP staff who get offended. A NGO field worker recalls that it took them 2 years to gain the trust of the local programme officers: When we were coming up with evident differences in the data, some of the medical officers at the TU [TB unit] level did not like it … Because they didn’t like us contributing to the quality of the programme, thinking unnecessarily that we were robbing the name or whatever it is, which was not our intention at all, because we never acted as competitors to the government service. We were only complementing their service. (Interview, international NGO fieldworker, Hyderabad, 24 February 2009) Furthermore, the RNTCP staff supervises external partners through their regular control visits and reports on the performance of the PPM partners. A RNTCP medical officer explains how she makes PPM work: I do a lot of fieldwork [to motivate private practitioners refer patients]. Otherwise it is impossible, sitting here and monitoring is not possible. I have to go into the field. (Interview physician RNTCP 3, Hyderabad, 14 March 2009) Yet she can only spare a few days a month of fieldwork and for the remaining days she sends her health workers. This is regarded as cumbersome, additional work for the RNTCP staff who are often overburdened with various tasks, given staff vacancies and lack of capacity in the health system. Qualified private practitioners resent these new forms of supervision. They experience supervision by an RNTCP staff member who is often less senior than themselves as disturbing (their work), inadequate and suspect (interviews, international NGO field worker, Hyderabad, 24 February 2009; private physician 3, Hyderabad, 27 February 2009). As the first author observed during field visits, contact among equal peers (at a similar level in the professional hierarchy, for example between RNTCP physicians and private practitioners) is often lacking. As a private physician involved in the PPM activities of IMA explains: There would be some expectations from the government that IMA can sort of order the private doctors, which is not possible. Nobody takes orders … in private practice from anybody. They work on their own. So what we have to do is encourage them, sensitise them, counsel them … See the government, what do they do? They just can give an order. You have to be here, you have to go to the field. (Interview, Hyderabad, 25 February 2009) Private practitioners regard their own contribution to PPM as taking over work of the RNTCP, which is not able to perform properly, but then exercises control over them and thereby threaten their professional autonomy. (Interviews, IMA consultant 1, Delhi, 19 January 2009; IMA consultant 2, Hyderabad, 25 February 2009) In short, in the PPM initiatives control in the form of supervision of patients is relocated from the TB programme to the private practitioner and new forms of supervision emerge that can be resented by public workers for being too cumbersome and by the private providers for being too controlling. Secondly, PPM implies changes in standards, which are set out in the ‘RNTCP Revised Schemes for NGOs and Private Practitioners’ (Central TB Division 2008). Detailed reporting and recording mechanisms as well as operational and technical guidelines are central in the © 2013 The Authors Sociology of Health & Illness © 2013 Foundation for the Sociology of Health & Illness/John Wiley & Sons Ltd

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organisation of the RNTCP. The extent to which guidelines are applied in the practices of private practitioners varies widely, due to the differences in qualifications and specialisations among private practitioners. According to the early innovators of PPM, the new guidelines are not adequate for regulating PPM because they are not linked with performance indicators and PPM does not have a specific budget in the RNTCP. According to an IMA consultant: Even today in our CTD [Central TB Division of the RNTCP] there is no budget head to PPM! … it is concealed under different heads … So the DTO [district TB officer] who doesn’t want to do PPM can get away with it, and there are no indicators to measure PPM. (interview, 1, Delhi, 19 January 2009) The lack of clear demands, indicators and formalities allows district TB officers to circumvent PPM activities. This finding has been confirmed by a recent evaluation of the intensified scaling up of PPM covering a population of 50 million in 14 major cities by the RNTCP (Lal et al. 2011). It makes PPM a laborious additional task that does not show any impact on the RNTCP programme indicators, cannot be easily measured and thus has no immediate benefit for the health staff in charge (interview, IMA consultant 1, Delhi, 19 January 2009). Yet the need for performance indicators in order to make PPM work is the result of the target orientation that is part of the culture of control by the RNTCP itself. NGOs and private practitioners, on the other hand, need to show a strong and active interest if they want to contribute to the RNTCP. They apply for a PPM to district TB officers who might or might not accept their PPM projects. The RNTCP is waiting for applications. Thus, the policy schemes do not imply that the RNTCP actively fosters PPM, which actors from all three initial PPM models have complained about (interviews, international NGO field worker, Hyderabad, 24 February 2009; physician NGO 1, Mumbai, 18 December 2008). According to some, the new standards control PPM too little. According to others, the new standards control PPM too strictly, are too prescriptive for local contexts and limit local creativity and innovation. The guidelines offer collaboration in a sort of cookbook reicipe from which external partners can chose what ingredients they want to use. A PPM initiative focused on working with alcoholics, for example, who are a group vulnerable to TB and face specific challenges, is not part of those options. As the programme manager explains: That is one of the reasons why private physicians and NGOs are very reluctant to join RNTCP schemes, because there it is very prescribed and very limited what you can do. For example, the alcoholics, they may get questioned for that, why are you working with alcoholics? (Interview, international NGO programme manager 5, Delhi, 23 January 2009) The private practitioners respond differently to control by standardisation; some applaud it, while others oppose it because they feel threatened in their professional autonomy (Interview, IMA consultant 1, Delhi, 19 January 2009). This finding has been confirmed elsewhere (Waring 2005). Thirdly, there are different organisational cultures of control and PPM demands changes to be made to organisational culture and ideology. The RNTCP has set up a strong bureaucratic management of the programme to reach targets, such as certain levels of detection, conversion and cure rates. In order to do so, it makes use of various forms of supervision and a command and control style management, which are all part of a bureaucratic and hierarchical organisational culture. ‘We want them to come into the guidelines’ is how a RNTCP physician puts it (interview, 3, Hyderabad, 14 February 2009). Qualified private practitioners have in general strong apprehensions of rule-based managerial practices. The medical practice of private © 2013 The Authors Sociology of Health & Illness © 2013 Foundation for the Sociology of Health & Illness/John Wiley & Sons Ltd

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practitioners is based on ideals such as individualism, discretion and autonomy and is linked to their focus on individual rather than public health (Waring 2005). Several of the interviewees have remarked critically that the culture of command and control of the RNTCP is being extended into the PPM activities. Critics argue that this organisational culture of control limits innovations, such as PPM, and their further development (interview NGO consultant, activist, Delhi, 16 January 2009; head of a national NGO, Hyderabad, 25 November 2008; international NGO programme manager, Hyderabad, 24 March 2008).

Discussion: conditions of PPM The results of the three different PPM initiatives show that individual innovative efforts are not coordinated. Nonetheless, the three models have a lot in common: they documented many ideas in research studies, were run by committed individuals and used data and political influence (through the WHO or the private medical lobby) to advocate for them (Copreaux and Dholakia 2003, Kumar et al. 2005, Murthy et al. 2001, Rangan et al. 2003). However, the three models differ in their suggestions as to what problem PPM should address, how the PPM activities should best be run and scaled up, and their understanding of who would be the main actor responsible for it (the government, an NGO or a professional association). Thus, the three models all emphasised different problem definitions and solutions for PPM activities. These differences are linked to the actors’ professional practices, which imply an individual health, public health or community perspective on TB. Yet these different problem definitions and practices were not sufficiently negotiated when the PPM guidelines were designed and they were only partially endorsed and integrated into the subsequent countrywide PPM activities by the RNTCP. Taking into consideration these differences in the three PPM initiatives and in practicing organisational control of supervision, standards and culture, the Kerala model by IMA fits easiest with the RNTCP’s problem definition and organisational control practices, because it approaches PPM with a top-down approach and view on patients that is similar to the TB programme. IMA focuses on qualified private practitioners rather than unqualified slum doctors, who are difficult to incorporate from a programme perspective, and does not involve overly laborious processes for RNTCP staff (interview, private physician 3, Hyderabad, 27 February 2009; 2, Hyderabad, 24 November 2008; NGO programme manager 1, Mumbai, 19 December 2008). The other models demand a huge workload for RNTCP staff and require substantial changes in problem definitions and organisational control practices. This makes it more difficult for them to be adopted by the RNTCP and harder to replicate. IMA is able to replicate their PPM model immediately through their local branches across the country. PPM requires negotiating different problem definitions and changing, balancing and bridging very different practices of supervision, standards and organisational culture. These findings specify and expand on earlier findings that implementing PPM guidelines requires a strong commitment of the public TB programme to build up trust (Mahendradhata et al. 2007), to engage in coordination and stewardship (Unger et al. 2010) and to manage processes of collaboration over time (Probandari et al. 2011). Our results show that issues of trust, in particular, come to the fore when transferring supervision to other partners, while the IMA model emphasises that the main problem of PPM is a lack of trust between providers. Yet the IMA model offers little advice on how to sustain and manage a relationship that builds trust over time and it does not take into account trust issues in transferring supervision practices between providers. The other PPM models criticise precisely this point and offer different ways of managing relationships between providers. Managing coordination processes in such a © 2013 The Authors Sociology of Health & Illness © 2013 Foundation for the Sociology of Health & Illness/John Wiley & Sons Ltd

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way is, according to Lal et al. (2011), challenged by the Indian TB programme′s own lack of interest in PPM and its lack of faith in its own capacity to deal with private practitioners. Our results also reveal how professionalisation, status and professional autonomy feature in the control practices of supervision and culture. Yet these differences are not adequately taken into account by the current PPM efforts of the RNTCP. The Mahaveer model highlights the lack of respect shown to different professionals as one of the main challenges in making PPM work. Showing unqualified practitioners respect is difficult for the RNTCP as doing so acknowledges their practices as justified. However, our material also shows that qualified practitioners resent the supervision practices of the RNTCP, as they are often executed by staff of a lower professional status to the supervisee and are contrary to the claim of professional autonomy that is at the core of the private practitioners’ culture of control. Consequently, some early innovators are disappointed about how PPM is being scaled up by the TB programme through both guidelines and the involvement of IMA. There is thus a mismatch of control practices, including the underlying problem definitions between some of the initial PPM models and the scaling-up efforts by the RNTCP. These mismatches and differences are fostering acts of blame which challenge PPM. Our study confirms previous results in that a lack of willingness to interact hampers the implementation of PPM. Yet our explanations for these implementation problems are not the same as the different views on the importance of PPM and mutual lack of trust (De Costa et al. 2008, Uplekar et al. 2001). Instead, we locate them as arising during the design of the partnership guidelines. We highlight that the different problem definitions that PPM need to address and the actors′ different control practices with regard to supervision, standards and culture were disregarded, all of which resulted in reinforcing professional boundaries instead of relaxing them. We conclude that PPM activities face difficulties in implementation because the way these models have been institutionalised does not take the diversity of practices and understandings into account. The analysis of different problem definitions and control practices explains why it is crucial to negotiate this diversity. How then, can organisational innovation, such as PPM, be scaled up and fostered without jeopardising organisational control? And how can organisational control be exercised without stifling the innovative activity of the organisation’s members? Based on the results presented above, we argue that the relationship between innovation and organisational control cannot be solved once and for all. The differences in control practices mean that actors may arrive at different innovation-control dilemmas. From the perspective of the RNTCP, innovation involves the risk of losing control. The potential loss of control over patients, drugs and data is feared by the RNTCP and is a source of apprehension of the PPM. For the RNTCP staff, the PPM lacks organisational control in the form of performance-related indicators for PPM in the RNTCP guidelines. Consequently, some staff cannot afford to spend time and effort on PPM because it offers them no incentives and does not contribute to their measurable performance. On the other hand, the guidelines for PPM exert too much organisational control for some actors in the private and NGO sector, who need more room to try out new ideas or who resist standardisation because they feel threatened in their professional autonomy. Our results suggest that these different dilemmas need to be made explicit by the actors in a non-blaming way. The relation between innovation and control needs to be continuously negotiated between the different professional groups involved in organisational innovation. This article constitutes therefore an important contribution to the literature on PPP that has recognised the importance of managing collaborations (Ramiah and Reich 2006) but has so far failed to pay attention to the different ways of handling innovation and control. The lack of attention to such differences is one of the reasons why PPM is facing challenges in being scaled up. © 2013 The Authors Sociology of Health & Illness © 2013 Foundation for the Sociology of Health & Illness/John Wiley & Sons Ltd

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Conclusion The main argument of this article is that practices of innovation and control in PPM provide important conditions for the sustainability and viability of PPM initiatives. The results add to explanations for the implementation problems of partnership initiatives in the literature on PPM and the role of the private sector in low-resource settings. Our analysis of PPM in India as a case of organisational innovation led to our focus on problem definitions and organisational control practices. In answering our research questions we show that organisational innovations are initiated by committed individuals and are supported by data and policy change. Yet some early innovators are disappointed with how PPM is being scaled up by the TB programme. We show that, when making their way through the control structure, these innovations tend to suffer from conflicting problem definitions, nonaligning forms of control and reinforced professional boundaries. Organisational control practices, including supervision, standardisation and culture, matter because they vary greatly between different professions and may thwart PPM. What can we learn from that about the scaling up of PPM? PPM requires changing, balancing and bridging very different practices of supervision, standards and organisational culture. These different control practices tend to clash with each other and foster criticism for not providing good care. Making PPM work requires bridging the particular organisational culture of the RNTCP (control and command), the private practitioners (control-aversive but with a professional monopoly) and the NGOs (which are community oriented and participatory in character). In the cases of PPM we studied, there was no open negotiation of underlying problem definitions, the different control practices involved and the different ways of handling innovation and control. On the contrary, we also showed that the solutions that were picked up were the ones that fitted most easily with existing problem definitions and control practices of the decision-makers. These differences continue to clash and cause apprehensions of PPM and ultimately hinder scaling up and innovative activity. Complex organisational settings like TB control need to cope with the relationship between innovation and control to engage successfully in PPPs. Address for correspondence: Nora Engel, Department of Health, Ethics and Society/School for Public Health and Primary Care, Faculty of Health, Medicine and Life Sciences, Maastricht University, PO Box 616, NL 6200 MD Maastricht, The Netherlands. e-mail: [email protected]

Acknowledgements We would like to thank the participants of this study who offered their time and insights. We would also like to thank United Nations University and Maastricht University for funding the fieldwork of the first author. We appreciate the administrative support during the fieldwork of the Link Secretariat at the Centre for Research on Innovation and Science Policyin Hyderabad, India.

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