1.1 Accessible and acceptable healthcare services.

IPs were recognized as trusted healthcare providers with established close relationships in the community. One participant emphasized their dedication to patient care, stating, “we care about these patients and take the time during consultations, which is why patients are happy with our services” (IP, 47 M, Post-Sec.). One IP shared how such relationships create a safe environment where patients feel comfortable sharing information with them. Another IP specifically referenced TB explaining how IPs’ round the clock availability in the community increases the probability of identifying a presumptive TB case at the community level. Most FPs acknowledged the convenience of health services offered by IPs. They also emphasized the positive impact of IPs’ strong community relationship to the NTEP, as expressed by one FP, “As IPs have been working at the community level for a long time, they have an excellent understanding of their service area. Therefore, their engagement would benefit the NTEP” (FP).

1.2 IPs role as a primary care provider.

Both IPs’ and FPs’ narratives indicated the crucial role of IPs as primary care providers in the community, often acting as a first point of contact for patients. For example, one IP mentioned that people often visited them with “common complaints such as fever, cold, cough, loose motion, diarrhoea, and other general complaints. Initially, when patients visit us, we provide some treatment. If the patient’s health does not improve, then we refer them to higher health facilities” (IP, 44 F, Post-Sec.). IPs mentioned that their service area includes rural and underserved parts of the communities, so they recognize their role as a primary care provider. One IP shared, “my working area is remote and includes villages near rivers, tribal communities where people have low literacy and belong to low socio-economic background” (IP, 38 M, Post-Sec.). FPs agreed that, for general symptoms such as cough and cold (common symptoms for TB), IPs are often the first go-to provider in the local community, particularly in remote areas.

As referenced above, most IPs viewed their role as a link between the community and the health system by providing primary care and making an appropriate referral to higher health system levels when necessary. FPs shared similar perspectives, with one FP stating, “we have engaged IPs in TB care (for referral) because they are high in number and act as a first point of contact, offering primary health care to people in the community” (FP).

1.3 Competing tasks and priorities.

Despite their wide acceptance and close proximity to the community, engaging IPs in formal programs, including TB care requires careful consideration. Participants reported that working as an IP was their primary occupation and sole means of livelihood, so hesitancy was noted among some IPs to dedicate substantial time to the NTEP. One IP expressed this concern, stating, “This is my primary profession, so if I work in the National TB Program, it will impact my clinic hours and patient load. Therefore, it is important to receive financial support for our work in TB care” (IP, 38 M, Post-Sec.). As indicated in the quote, an agreement was noted among IPs to adjust their work schedule if the government provided some remuneration for their work in TB care. FPs also acknowledged this challenge, with one remarking, “They can refer presumptive TB cases from their clinic as part of their regular practice. However, if we restrict them to a fixed work schedule and assign responsibilities outside of their clinic, they may become demotivated as working as an IP is their primary occupation" (FP). This underscores the necessity of aligning the roles assigned to IPs with their existing work structure.

1.4 Quality of care.

Participants from both groups raised concerns regarding the quality of care provided by IPs. A small number of IPs mentioned that some fellow providers serving in their community lacked appropriate knowledge and suggested that their practices should be closely monitored by the formal health system. An IP highlighted this issue stating, “Birasadpur (pseudonym used) village has few IPs who are practising because their father used to work as an IP. I don’t want to comment further, but they need to be monitored” (IP, 43 M, High Edu.).

There was also self-admission of a lack of knowledge in certain aspects of TB care by IPs. As one participant expressed: “We do not have sufficient knowledge regarding TB care, especially in areas such as administering TB treatment. Therefore, we need more training related to these topics” (IP, 33 M Post Sec.). A gap in knowledge was mentioned by another IP, stating that “currently, we suspect and refer patients, but the number of confirmed cases is low” (IP, 36 M, Post-Sec.). FPs also recognized the knowledge gap among IPs, with one FP mentioning “there is a knowledge gap as they are not trained in TB care. For example, they lack knowledge about adverse drug reactions and appropriate medication doses, particularly for Drug Resistant (DR)-TB” (FP).

2.1 Lack of role clarity in TB care.

The current engagement of IPs in the NTEP, limited to the referral of presumptive TB cases to government health facilities was confirmed by FPs from various levels of the health system. One formal provider shared that, “for the last two years, we have been training IPs in Birbhum district. They have been trained to identify four symptoms (S): cough for two weeks, fever, weight loss, and night sweats. We have asked them to refer any patients with four “S” to the nearest health centre or a designated microscopic centre” (FP).

Despite these efforts of the state government, there remains a lack of clarity regarding the role of IPs in providing TB care. IPs expressed that this was primarily due to a lack of clear and specific instructions and guidelines, with one IP stating “we are just told to refer any presumptive cases, but there exists no guideline for us to follow” (IP, 54 M, Higher Edu.). Another IP highlighted the need for further guidance on systematic case identification, decision making approach regarding referrals, and proper case record management.

In contrast, FPs had a clear understanding of the roles of formal private providers, such as private doctors, as outlined in TB guidelines. As shared by one FP: “The guideline states that if a formal private doctor diagnoses a case of TB and makes a referral, the patient treatment card will be prepared based on their diagnosis, and no further test will be required” (FP). Similarly, another FP noted, “we have clear instructions for pharmacies. If any patient visits them for treatment, they must either inform a nearby hospital or notify through the NTEP portal” (FP). However, ambiguity was observed in the case of IPs. One formal provider explained “the national guideline outlines that anybody can be a treatment supporter, including formal health workers, community and family members. As IPs are from the community, they can also play this role. But IPs are not specifically mentioned in the guideline” (FP). Essentially, the current TB guidelines equates the role of IPs to that of any other community member.

2.2 Lack of systematic monitoring system.

The lack of a systematic monitoring system was highlighted by those IPs who were currently engaged (n = 10) in the government program for referral of presumptive TB cases. They expressed a need for an organized approach to monitor their engagement. Some IPs who had undergone the training program which was offered by the government before their engagement mentioned that there was no follow-up or monitoring after the completion of the training. One IP expressed their concern stating, “now the situation is like they gave us the training, but they don’t know who is working or not. There is a wide gap in monitoring” (IP, 48 M, Sec.).

Several FPs also acknowledged the absence of a monitoring plan and system for IPs in the current engagement program, with one explaining “there is no specific guideline to visit informal rural practitioners (IPs) regularly. We currently focus on formal private practitioners during our monitoring visits” (FP).

IPs suggested the need for regular monthly or quarterly interactions to discuss progress and challenges faced in the field. As one IP shared, “government should organize regular meetings with IPs. During these interactions, IPs can share their experiences and difficulties encountered. Also, this will enable the government to monitor IPs’ progress” (IP, 65 M, Post-Sec.). FPs shared similar opinions regarding the importance of organizing regular meetings with IPs. One FP further explained that such activities would motivate IPs and help the formal system track their progress. Additionally, one FP proposed to discuss data related to referrals made by IPs during these meetings.

2.3 Inclusive incentive system.

The provision of incentives to IPs for referrals of presumptive cases after confirmation of TB (as per the norms of NTEP) was confirmed by both FPs and IPs. IPs expressed their satisfaction with the monetary compensation provided for their referrals. One engaged IP shared, “we were told that if a referred patients test positive by sputum test either in King (pseudonym) hospital or Block Primary Health Center (BPHC), we will get 500 rupees per patient” (IP, 48 M, Sec.).

FPs also shared enthusiasm for expanding the incentive system to include additional roles for IPs, such as treatment-supporter and transportation of sputum samples. As explained by one FP, “we have a provision of incentivizing treatment supporters. For a normal TB patient, one treatment supporter can get a thousand rupees per month (for six months) after the patient completes the treatment. IPs can also be included as treatment supporters” (FP).

Despite having an inclusive incentive scheme, several IPs reported shortcomings, primarily attributed to the lack of a systematic patient-tracking system. One IP expressed dissatisfaction with not receiving an incentive for a referred patient recounting the following experience: “I referred two patients with a signed form to Harinagar (pseudonym used) BPHC, and they tested positive for TB. When the patient was under treatment, I enquired many places about the referral form I sent with the patient, but I was told no such form was received. I contacted a local health worker, and she explained that the case was registered under someone from the Udayapura (pseudonym used) hospital” (IP, 43 M, High Edu.).

From IPs’ narratives, the primary reason for the lack of a systematic patient-tracking system was the current paper-based referral system, which was reported to be ineffective. FPs also acknowledged the limitations of the paper-based referral system and identified two key problems. Firstly, patients who are referred by an IP may visit another private provider before going to a government facility, resulting in the case being registered under the name of the last provider instead of the IP who made the initial referral. Secondly, patients visiting government health centres may not bring or show the referral slip, leading to challenges in accurately attributing the referral to the IP. IPs recommended the implementation of a tracking system that would provide them with information about the outcome of their referrals and ensure better coordination between providers.

2.4 Evolving recognition in the health system.

The recognition of IPs by the state government of West Bengal may have had an impact on their expanded engagement in various formal health programs. One FP mentioned, “IPs are a special group of human resources who can be effectively utilized in public health programs with proper sensitization and regular training” (FP).

FPs commonly referred to IPs as an integral part of the rural health system and a crucial link to connect people to the formal health system. Some IPs shared their experiences of receiving appreciation from FPs and cited it as an important motivating factor: “Some doctors appreciate us and say “gramin chikitsak” (IPs) are doing fantastic work. They like us and consider our role to be important in strengthening patient referral” (IP, 47 M, Post-Sec.). The evolving relationship between the two systems was also visible through IPs’ engagement in other government programs such as the pulse polio vaccination and household surveys which were mentioned by a few IPs.

IPs emphasized the importance of government recognition of their roles in the health system. They mentioned that recognition enhances their acceptance in the community as well as among FPs, building trust among the people they serve and providing them with due credit for their contribution to the health system. As one IP expressed, “with government recognition, people come to us with more trust” (IP, 43 M, High Edu.).

2.5 Gaps in the current engagement program.

The West Bengal state government’s efforts to engage IPs for referral of presumptive TB cases faced several challenges. The first noted challenge was the low coverage, as only a limited number of IPs participated in the program. As one IP shared, “some Rural Healthcare Providers (RHCPs) (IPs) from my area went for the training at BPHC, but I don’t think all of them are currently referring patients” (IP, 54 M, High Edu.).

One IP who was not engaged in the program expressed dissatisfaction with being excluded and mentioned that neither he nor other IPs in the neighborhood were invited to participate. This exclusion could be attributed to the enrolment process, as the listed IPs were only designated the role of referring presumptive TB patients. A formal provider stated, "We asked to submit the block-wise list of practicing IPs. Once we enlisted their name, they were assigned the role to formally refer presumptive TB patients after undergoing training. (FP)" One engaged IP suggested that involving local IP associations could enhance the participation of all IPs in the program. The second challenge observed was the low number of TB-positive results returned among presumptive TB cases referred by IPs. As shared by one IP, “I send patients for TB testing, but they don’t test positive. Even this month, I had sent 2–3 patients with symptoms, but they all tested negative for TB” (IP, 47 M, Sec.). Some IPs shared that the training they received before their engagement in the program was insufficient to enhance their TB care knowledge. For example, one IP explained that “of course, we need training. I already told you that the training we received was delivered for a short time, one-time basic training probably for 1 hour delivered by a madam at Narayani (pseudonym used) hospital” (IP, 36 M, Post-Sec.).

Some FPs recognised that the existing referral system has certain gaps and shortcomings, primarily because the engagement of IPs in the program is a relatively recent development. Furthermore, one FP highlighted that the data has not yet been systematically reviewed to evaluate the overall impact of the engagement of IPs on a broader level: “After IPs’ engagement for patient referral, we have not yet reviewed the outcome of this program at the […] level. But I have been informed by a few [..] that the IPs have started to refer cases, and hopefully, it will increase the case number”. (FP).

3.1 Willingness to work together.

FPs expressed their willingness to collaborate and work with IPs, recognizing the valuable role they play in TB care. They were open to exploring additional responsibilities for IPs within the framework of the NTEP. For example: “We carried out a pilot project engaging IPs in the Barahi (pseudonym used) area. IPs were engaged as patient sample-carriers and for referrals. We completed that project and found that IPs can be effectively utilized in TB program with appropriate training” (FP).

Similarly, IPs demonstrated a strong willingness to work with FPs, expressing enthusiasm for their participation (among those who had not yet participated) and a desire to continue working with the government despite the challenges faced in the current engagement (by those IPs currently involved). As described by one IP who was not currently engaged, “I am telling you, I am very willing to take responsibilities assigned to me in the National TB Program” (IP, 45 M, High Edu.).

3.2 Expressed distrust between stakeholders in the two systems.

Even though both groups demonstrated willingness, we also identified a sense of distrust between the two groups. Some IPs shared instances of neglect and discrimination from FPs in various settings. One IP noted “we are insulted by referring to us as “quacks”. In some government offices, we feel neglected” (IP, 45 M, High Edu.). Similarly, FPs acknowledged that there is a lack of acceptance of IPs as care providers among some formal health workers in West Bengal and India as a whole. Furthermore, misalignment was observed between ASHAs and IPs, who both provide healthcare services at the community level. ASHAs highlighted their formal status within the healthcare system and emphasized their ability to provide care to TB patients more efficiently: “We are part of the formal system, so we are allowed to act as treatment supporters to patients. The medicines are dispensed from the government health facility, so IPs do not have access to TB medicines” (Formal Provider, ASHA). A similar sentiment was noted among some IPs who stressed that IPs possess better skills and experience in providing care to TB patients in the community compared to other community-based health workers; as stated by one IP, “if we [IPs] see a presumptive TB case, as we have 10–30 years of experience and also treat people with diseases, we can easily identify and refer them, so we are better suited for such roles in TB care [..]” (IP, 38 M, Post-Sec.)