A study has found that in 2014 there were 2.2 million TB patients treated in India’s private sector alone. This is 2-3 times higher than current estimates.

In all probability, the higher TB burden in the private sector might still be an underestimation as drug-resistant TB cases were not taken into account. Thus, the private sector is treating an enormous number of patients for TB, appreciably higher than has been previously recognised. In contrast, the State-run Revised National Tuberculosis Control Programme (RNTCP) treated 1.42 million TB patients in 2014.

According to a 2015 WHO report, six million new TB cases were reported to WHO from across the world in 2014. And India’s TB contribution accounted for 26 per cent of these reported cases. But based on the results of the study, a major revision of the TB burden estimates in India and worldwide might be required. Under-reporting of TB cases could be significantly fuelling drug resistance and have implications for patients across the globe.

More importantly, the results of a study published on August 25 in the journal The Lancet suggests that TB incidence is considerably higher than previously recognised, Prof. Nimalan Arinaminpathy, the first author of the paper from the School of Public Health, Imperial College London, says in an email to me.

India has to redouble efforts to reach patients being treated in the private sector.

Lack of systematic data

Despite the private sector treating more patients than the public sector, systematic data on the private sector was lacking. So the study by Prof. Arinaminpathy looked at the sales of anti-TB drugs containing rifampicin by pharmacists across the country in 2013 and 2014. The team then used this figure to calculate the number of cases. The authors adjusted for TB overdiagnosis in the private sector. There was much variance in the number of patients treated in the private and public sector in different States. For instance, the public sector in Orissa had 1.5-2.8 times the volume of TB medicines prescribed than the private sector but Bihar had three times the volume of TB medicines prescribed in the private sector than public sector. But on a national level, there was nearly twice as much TB treatment in the private sector as in public sector in 2013 and 2014.

The 2.2 million cases treated in 2014 in the private sector was arrived at by considering that TB patients underwent four months of treatment on average and only 50 per cent of TB diagnosis in the private sector was correct. The number of patients treated in the private sector increases when higher accuracy of positive TB diagnosis and shorter average treatment duration were considered.

The results of the study have major implications for TB strategy for India. The disorganised private sector poses several challenges to TB control. Since free TB care is assured even to patients opting for private sector, India has to “redouble efforts to reach patients being treated in the private sector and to deliver the highest possible standards of TB care.”

Second, surveillance of TB in the private sector has to be strengthened. In 2014, as against 2.2 million cases, only a little over 100,000 cases were notified by doctors in the private sector. “But the government has been making strong progress in engaging with providers in the private sector. There has been a rapid increase of private-sector notifications in the last two years (there were essentially zero in 2011). These are encouraging first steps, and our results show the scale of the challenge ahead,” he says.

 Finally, there is a compelling need to find the true TB burden in the country. “TB burden is typically measured through TB prevalence surveys, the most recent of which was in Gujarat. We may soon see the opportunity to conduct these surveys more broadly across the country, which would cast critical light on the TB burden in India as a whole,” says Prof. Arinaminpathy.

There is an economic cost attached to the disease. Since TB treatment in private sector is met primarily by out-of-pocket expenditure, as no medical insurance in India covers treatment cost, a six-month treatment course for first-line TB drugs would cost $20. The 2.2 million patients seeking care in the private sector would have therefore spent $59 million for drugs alone.

Published in The Hindu on August 25, 2016