India’s huge burden of TB is treated in the private sector

Aarti Dhar, CNS Correspondent, India
[First published in]
India’s private sector is treating an enormous number of patients for TB, almost double the number than has been previously recognized and requires re-doubled efforts to address this burden and strengthen surveillance, a latest Lancet report has said. TB burden estimates in India and worldwide require revision, the report added. There were 17·793 million patient-months of anti TB treatment in the private sector in 2014, which was twice as many as in the public sector. If 40–60% of private-sector TB diagnoses are correct, and if private-sector TB treatment lasts on an average 2–6 months, this implies that 1.19—5.34 million TB cases were treated in the private sector  alone in 2014.

The midpoint of these ranges yields an estimate of 2·2 million cases— two to three times higher than currently assumed, according to the study "The number of privately treated tuberculosis cases in India: An estimation from drug sales data" published in the latest edition of the Lancet Infectious Diseases Journal.

The study is authored by Nimalan Arinaminpathy, Deepak Batra, Sunil Khaparde, Thongsuanmung Vualnam, Nilesh Maheshwari, Lokesh Sharma, Sreenivas A Nair, Puneet Dewan. Understanding the amount of TB managed by the private sector in India is crucial to understanding the true burden of the disease in the country, and thus globally. In the absence of quality surveillance data on privately treated patients, commercial drug sales data offer an empirical foundation for disease burden estimation. The researchers used a large, nationally representative commercial dataset on sales of 189 TB drugs available in India to calculate the amount of TB treatment in the private sector in 2013–14. To address implications for numbers of patients with TB, the researchers explored varying assumptions for average duration of TB treatment and accuracy of private diagnosis.

TB is a major global public health challenge. In 2014, 6·3 million cases of TB worldwide were reported to WHO, with India accounting for over a quarter of these cases—the highest of any country. Although standardised TB treatment in India is delivered by the public sector through the Revised National TB Control Programme (RNTCP), early diagnosis and treatment are hampered by the presence of a vast and unregulated private health-care sector. Poor diagnostic practices in this sector increase TB transmission by delaying diagnosis, whereas a general lack of counselling and support of treatment adherence hampers successful, relapse-free cure.

Moreover, most cases treated in the private sector are never notified to public health authorities. Estimating the numbers of patients being treated in the private sector is important for several reasons: it provides information about the performance of a public health system in detecting and treating TB cases, while also helping in planning for government intervention in the private sector. Overall, it is crucial to know the scale of the problem of the undetected burden that exists outside the public health system, the study said.

The findings have implications for the TB control strategy in India. The vast disorganised private health-care sector poses major challenges to TB control. India’s RNTCP has committed to providing free, high-quality TB care to patients in the private sector. Initiatives such as private-sector engagement to improve TB care in this sector, offer potential mechanisms for realising these goals. In this context, the results suggest that the scale of the challenge is substantially larger than has hitherto been appreciated. These findings underscore the need for redoubled efforts to reach patients being treated in the private sector, to deliver the highest possible standards of TB care.

It also recommends an urgent need for further strengthening of TB surveillance in the private sector. Although there has been increasing notification of TB cases by the private sector to public health authorities, these accounted for just 106414 patients in 2014—a level far below than estimated here. The findings highlight uncertainty around the true burden of TB in India. Methods for estimating this burden should be complemented by independent approaches generating primary data. In addition to the surveillance needs mentioned above, a national prevalence survey would provide direct evidence for the numbers of patients receiving treatment in the private sector, the study said.

Aarti Dhar, Citizen News Service - CNS
September 14, 2016