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Active private sector collaborations crucial for ending TB!

Mar 24, 2018

Though TB incidence and TB deaths have shown a declining trend, India continues to have the highest burden of TB, writes Dr. Rajna Mishra, Senior Research Scientist.

New Delhi: Globally 28 lakh patients are estimated to be suffering from TB and 4.8 lakh deaths have been attributable to disease. The estimated incidence of new TB cases in India in 2016 was 2.8 million cases and mortality due to TB was 480,000. Approximately 5% of the incident TB cases have co-morbidity with HIV, though this proportion varies depending on the HIV prevalence of the population.

Though TB incidence and TB deaths have shown a declining trend, India continues to have the highest burden of TB in the world accounting for one fourth of the global disease burden (TB incidence declined from 289 per lakh per year in 2000 to 217 per lakh per year in 2015 and TB deaths reduced from 56 per lakh per year in 2000 to 36 per lakh per year in 2015 as per the Global TB Report, 2016). Mortality due to TB is the third leading cause of years of life lost (YLLs) lost, in the country.

The country has varied epidemiology from very high TB prevalence to very low TB prevalence, high and low TB/HIV coinfection and drug resistant - DR-TB depending on state/regions. Rural-urban differentials prevail, urban areas are typically characterized by lower prevalence with higher Annual Risk of TB infection (ARTI), which rural areas are characterized by higher prevalence and lower ARTI.

But challenges remain

Diversity of TB epidemiology in the country necessitates different approaches to be adopted for addressing the problem. The private sector is massive, heterogeneous, and evidence suggests that attempts to improve collaboration between the public and private sectors, have not yet worked except in a few innovative pilots.

Private sector remains the first point of contact for many people with early symptoms of TB and over 80% first approach the private sector. Substantial diagnostic delays occur and diagnosis and treatment are of variable quality in the private sector. This, combined with the absence of drug quality controls, leads to drug resistance. Hence, this urgently necessitates enhanced engagement with the largely unorganized and unregulated private sector which accounts for at least half of those treated for TB in India.

Despite mandatory notification, notification in the country is abysmally low at 58% and many patients treated by the private sector are not notified to the RNTCP. India has more than a million ‘missing’ cases every year that are not notified and most remain either undiagnosed or inadequately diagnosed and treated in the private sector. Some of the other bottlenecks include absence of a policy for private sector engagement, utilization of funds earmarked for private sector for other activities, inappropriate tools, uncertain quality standards and high out of pocket expenditure.

Pathways to reach out to patients seeking care from the private sector:

Morbidity and mortality due to TB could be reduced by Private sector participation in early diagnosis, notification and management.

Though the government is putting in efforts to engage with the private sector and improve the quality of care, the nature of partnership should focus on both enabling service provision, stewardship and monitoring including a robust modern MIS system. As with public health services, there is an urgent need for surveillance, adherence monitoring, contact investigation, and outcome recording among privately-treated TB patients.

Public health actions to support increased private provider engagement for better health outcomes that needs to be addressed on an immediate basis should consider the following:

Comprehensive census of providers through a complete census/mapping of all private providers including private doctors (both Allopaths and AYUSH), chemists and laboratories.

Considering the large number of AYUSH providers in India, and lack of clarity on their involvement, a road map with clear cut guidelines and strategies to be laid down for enabling early case identification and prompt referrals.

It is to be ensured that all TB patients diagnosed or treated in private sector are notified. Provision of access to free drugs and diagnostic tests as per STCI, patient-centric adherence support to patients of private providers for retention in care, incentives and/or enablers to providers to be ensured through an explicit private sector engagement policy. There is a need to strengthening existing referral linkages and establish new linkages based on provider mapping for early and accurate diagnosis of TB and timely initiation of treatment, improved access to TB care, reduce patient drop-outs and increase patient satisfaction. Together with these, Innovative use of information and communication technologies for TB notification and treatment adherence monitoring is crucial. Sensitization and capacity building of private providers on standard treatment protocols (STCI) through CMEs, personal communication, professional associations etc., on an ongoing basis are to be provided.

The need of the hour lies in comprehensively-deployed interventions and strategies for public private partnerships to hasten the rate of decline of incidence of TB and move towards elimination and ensuring a “TB Mukt Bharat”.

The author is with the Public Health Foundation of India. Views expressed are personal.

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