TB: privately-treated patients, a concern

TB: privately-treated patients, a concern

India has been engaging in the fight against Tuberculosis (TB) since time immemorial, yet the country has the highest burden of TB and multi-drug-resistant TB (MDR-TB) in the world. This remains a major public health problem.

One-fourth of the global incidence of TB occurs in India annually despite the fact that the country possesses advanced and effective interventions and technologies on diagnosis, treatment and care. Revised guidelines, introduction of universal drug susceptibility tests and daily regimen as well as architectural reforms such as mandatory notification, integration with the National Health Mission etc have failed to control it.

Innovative and visionary electronic recording and reporting system (Project Nikshay), pilot approaches such as e-voucher systems for free drugs etc, too have been pressed into service.

The TB kills more than 1,400 Indians every day and an estimated 4,80,000 people in the country every year. As per the World Health Organisation’s (WHO) Global TB Report, 2015, out of the estimated global annual incidence of 9.6 million TB cases, 2.2 million cases occurred in India.

The country has more than a million ‘missing’ cases every year that are not notified (in spite of notification being mandatory, notification was abysmally low at 58% in 2015) or remains either undiagnosed, inadequately diagnosed and mistreated.

More than half the TB patients in the country first approach the private sector for treatment. However, substantial diagnostic delays, quality of care at the private facilities, absence of drug quality controls along with inadequate data and surveillance systems for privately-treated patients continue to be a matter of concern.

Also, there is a significant gap in the knowledge levels of the community on the preventive aspects of the disease and seeking early treatment from appropriate providers. Similarly, there are gaps in the knowledge and capacity of the private providers in adherence to standard treatment guidelines, notification, diagnosis and treatment.

Absence of a policy for private sector engagement, high out of pocket expenditure, lack of information on treatment practices adherence and treatment outcomes from the private sector, and use of funds earmarked for private sector for other activities at the state and district level further impact the control efforts.

Patients treated by private providers rarely receive sputum testing and drug susceptibility testing. Similarly, public health services such as surveillance, adherence monitoring, contact investigation, and outcome recording are almost non-existent among patients treated at private facilities.

However, the current appro­ach to treatment monitoring is health system centric rather than patient centric. Hence, diagnosis and treatment of TB in the private sector is both a boon and a bane.

Partnership management

Experiences from National Strategic Plan, 2012-17 indicated delays in payment, lack of clarity on performance expectations and poor partnership management as barriers for public-private mix. 

The National Strategic Plan (2017-25) proposes improving private health provider engagement through incentives, free drugs and diagnostics, support to patients through financial and nutritional incentives etc.

This calls for an urgent need to enhance engagement with the largely unorganised and unregulated private sector which accounts for at least half of those treated for TB through stringent policies for private sector engagement for adherence to standard treatment protocols.

There is also a need for innovative large scale strategies  which outline explicit frameworks for collaborating with the private sector for enhancing surveillance systems, quality assuran­ce, monitoring, increased control over drugs, capitalisation on advances in information and communication technology, increased use of accreditation and contracting mechanisms, increasing budgetary resources with earmarked resources for execution etc.

Besides, patients, civil society leaders and community-based organisations need to be meaningfully and intensively engaged in TB response at all levels to achieve universal access to TB care. For successfully moving towards TB elimination by 2025, it is essential to follow and strengthen the four strategic pillar approach of “detect, treat, prevent and build” innovatively.

(The writer is Senior Research Scientist, PHFI)