Without Better Private-Sector Care, India Cannot Eliminate Tuberculosis By 2025

Jaipur, Rajasthan: Only 35% cases of tuberculosis (TB)--an infectious air-borne bacterial disease that mostly affects the lungs--were handled correctly by the private healthcare sector in Mumbai and Patna between November 2014 and August 2015, according to a new study.

Untreated or partially-treated TB patients may infect others, at least partially nullifying India’s attempts to beat back a disease that claims nearly half a million lives every year, said the study published in September 2018 in the journal Plos Medicine, and jeopardise the country’s ambition of eliminating TB by 2025.

The private sector handles an estimated two-thirds of India’s 2.74 million new TB cases--the highest TB burden in the world. Better TB diagnosis and care in the private sector is key to achieving India’s goal of eliminating TB by 2025--reducing the number of cases to less than 10 per 100,000 from the current 204 per 100,000.

Treatment for TB includes a 6-month course of medicines, freely provided by the government’s Revised National Tuberculosis Control Programme (RNTCP). If not treated properly it can result in death, or the TB bacteria can mutate into a more potent form of the disease that is expensive to cure, and its treatment can often have debilitating side-effects.

“Poor quality TB care, according to the Lancet Commission on High Quality Health Systems, is responsible for 50% of all TB deaths,” said Madhukar Pai, director of the McGill International TB Center, and co-author of the study.

“India will have to develop its own unique strategies to handle the epidemic, which will necessarily involve working closely with the private sector as equal partners,” added Jishnu Das, lead economist in the Human Development Team at the World Bank, and one of the lead authors of the study.

The study was based on how doctors handled 2,602 fake standardised patients in Mumbai and Patna. Doctors included those who had bachelor of Medicine, Bachelor of Surgery (MBBS) or higher degrees; those who were Ayurveda, Yoga, Unani, Siddha, or Homeopathy (AYUSH) practitioners--with degrees in alternative medicine or traditional systems of health, and providers with other or no formal qualifications. The authors did not study follow-up visits and subsequent handling of cases.

The study was conducted by experts from a number of organisations including the World Bank, the McGill International TB Center, the Institute for Socio-Economic Research on Development and Democracy, and funded by the Grand Challenges Canada, the Bill & Melinda Gates Foundation, and the Knowledge for Change Program at the World Bank.

The study was part of a programme to include more private sector patients in the RNTCP by providing access to free drugs and incentives to doctors and pharmacists to report the case to the government. (To read more about the private sector engagement programme, here is our award winning story on how it is helping private sector patients in Gujarat’s Mehsana.)

Unnecessary medicines, antibiotics given to patients with TB symptoms

The study created four kinds of fake TB patients: One that had a classic case of presumed TB with cough and fever of 2-3 weeks, the second that had a cough and fever for 2-3 weeks and had been treated by another doctor with antibiotics, third that had a chronic cough and the results of a sputum test (which can detect TB in some cases), and the fourth was a case of chronic cough with a history of previous incomplete TB treatment. Whether these cases were handled correctly or not was measured against the World Health Organization and India’s standards for TB care.

The 2,602 standardised patients went to a representative sample of 473 healthcare providers in Patna, and to 730 providers in Mumbai. The authors weighted these to represent 3,179 eligible providers in Patna and 7,115 eligible providers in Mumbai. In 959 out of 2,602 cases (36.8%, or 35% if extrapolated to all eligible providers in the study), patients were managed correctly, in the form of referrals to a public healthcare facility for further treatment or by ordering chest X-Rays to test for TB.

Still unnecessary medicines were given to nearly all patients, and antibiotic use was common, the study found. Even non-MBBS doctors, who cannot prescribe allopathic medication, did so in many cases. Anti-TB drugs were prescribed in 118 cases, out of which only 45 were given the right treatment, mostly by MBBS-qualified doctors.

Doctors ordered sputum smear testing, which can help detect TB in the sputum, in 389 of 2,602 (equivalent to 18% of all eligible providers in the study) cases while recommending a test for Rifampicin resistance--one of the main anti-TB drugs--in 108 of 2,602 cases (equivalent to 2% of all eligible providers in the study), the study found.

The authors did not find any typical alternate pattern of treating patients, such as one that might be an outcome of urban pollution. For instance, doctors might provide symptomatic relief for a patient’s cough in a place marked with high pollution, instead of suspecting TB.

Connecting patients with high quality doctors, awareness on correct antibiotic use could improve TB care

“The quality of TB care in urban India is highly varied--there are some providers who get every case wrong, but there are also those who are providing excellent care. It is key to connect patients with the doctors who provide excellent care,” Das said.  

High patient loads were not responsible for low quality care, as “of the 2,602 interactions, 45% had no other patients waiting, 65% had a queue of 1 or fewer, 75% had 2 or fewer, and 95% had 10 or fewer,” the study found.

Quality deficits were not driven by either knowledge gaps or financial incentives alone, the authors of the study wrote, adding that the incorrect handling of cases is a combination of both. The authors found that if a doctor was given more proof of a TB diagnosis such as a sputum report, the doctors were more likely to provide better quality of care, showing a lack of knowledge.

But, at the same time, the quality of diagnosis did not improve in all cases where test results were provided, and had little effect in reducing inappropriate medicine use, suggesting that increased awareness would not completely solve the problem.

“There is a lot of scope of improving the standards of care in the private sector,” said Yatin Dholakia, honorary secretary and technical advisor to the Maharashtra state anti-TB association. Associations such as the Indian Medical Association, the association of chest physicians in India, association of AYUSH doctors, medical colleges, should provide structured training to doctors, Dholakia said. He also suggested trainings be organised through non-governmental organisations in partnership with Mumbai’s municipal corporation because such sessions organised by the government alone often have limited response.

Use of fluoroquinolones and steroids, which were found to be common practices in the study, can be extremely harmful, and greater awareness around that could reduce their use, Das, one of the lead authors of the study suggested.

As the private sector engagement programme in Mumbai and Patna scaled up, more private doctors registered TB cases with the government, and recommended microbiological tests, suggesting that such programmes could help improve diagnosis and care, said Das.

The results of the programme should be studied in detail to understand how the standard of care has changed over the past four years since this study was conducted, said Dholakia, which could guide future interventions to improve the quality of care.

Registering more cases with the government could help. Still, in the public sector too, success of treatment is not as high as the government numbers would suggest, as we reported in November 2016. Only 73% of one kind of TB cases registered for treatment were successfully treated, much lower than the government-reported 84% success rate, according the study published in the United States and United Kingdom-based health journal Plos Medicine.

(Shreya is a writer and editor with IndiaSpend.)

We welcome feedback. Please write to respond@indiaspend.org. We reserve the right to edit responses for language and grammar.

Jaipur, Rajasthan: Only 35% cases of tuberculosis (TB)--an infectious air-borne bacterial disease that mostly affects the lungs--were handled correctly by the private healthcare sector in Mumbai and Patna between November 2014 and August 2015, according to a new study.

Untreated or partially-treated TB patients may infect others, at least partially nullifying India’s attempts to beat back a disease that claims nearly half a million lives every year, said the study published in September 2018 in the journal Plos Medicine, and jeopardise the country’s ambition of eliminating TB by 2025.

The private sector handles an estimated two-thirds of India’s 2.74 million new TB cases--the highest TB burden in the world. Better TB diagnosis and care in the private sector is key to achieving India’s goal of eliminating TB by 2025--reducing the number of cases to less than 10 per 100,000 from the current 204 per 100,000.

Treatment for TB includes a 6-month course of medicines, freely provided by the government’s Revised National Tuberculosis Control Programme (RNTCP). If not treated properly it can result in death, or the TB bacteria can mutate into a more potent form of the disease that is expensive to cure, and its treatment can often have debilitating side-effects.

“Poor quality TB care, according to the Lancet Commission on High Quality Health Systems, is responsible for 50% of all TB deaths,” said Madhukar Pai, director of the McGill International TB Center, and co-author of the study.

“India will have to develop its own unique strategies to handle the epidemic, which will necessarily involve working closely with the private sector as equal partners,” added Jishnu Das, lead economist in the Human Development Team at the World Bank, and one of the lead authors of the study.

The study was based on how doctors handled 2,602 fake standardised patients in Mumbai and Patna. Doctors included those who had bachelor of Medicine, Bachelor of Surgery (MBBS) or higher degrees; those who were Ayurveda, Yoga, Unani, Siddha, or Homeopathy (AYUSH) practitioners--with degrees in alternative medicine or traditional systems of health, and providers with other or no formal qualifications. The authors did not study follow-up visits and subsequent handling of cases.

The study was conducted by experts from a number of organisations including the World Bank, the McGill International TB Center, the Institute for Socio-Economic Research on Development and Democracy, and funded by the Grand Challenges Canada, the Bill & Melinda Gates Foundation, and the Knowledge for Change Program at the World Bank.

The study was part of a programme to include more private sector patients in the RNTCP by providing access to free drugs and incentives to doctors and pharmacists to report the case to the government. (To read more about the private sector engagement programme, here is our award winning story on how it is helping private sector patients in Gujarat’s Mehsana.)

Unnecessary medicines, antibiotics given to patients with TB symptoms

The study created four kinds of fake TB patients: One that had a classic case of presumed TB with cough and fever of 2-3 weeks, the second that had a cough and fever for 2-3 weeks and had been treated by another doctor with antibiotics, third that had a chronic cough and the results of a sputum test (which can detect TB in some cases), and the fourth was a case of chronic cough with a history of previous incomplete TB treatment. Whether these cases were handled correctly or not was measured against the World Health Organization and India’s standards for TB care.

The 2,602 standardised patients went to a representative sample of 473 healthcare providers in Patna, and to 730 providers in Mumbai. The authors weighted these to represent 3,179 eligible providers in Patna and 7,115 eligible providers in Mumbai. In 959 out of 2,602 cases (36.8%, or 35% if extrapolated to all eligible providers in the study), patients were managed correctly, in the form of referrals to a public healthcare facility for further treatment or by ordering chest X-Rays to test for TB.

Still unnecessary medicines were given to nearly all patients, and antibiotic use was common, the study found. Even non-MBBS doctors, who cannot prescribe allopathic medication, did so in many cases. Anti-TB drugs were prescribed in 118 cases, out of which only 45 were given the right treatment, mostly by MBBS-qualified doctors.

Doctors ordered sputum smear testing, which can help detect TB in the sputum, in 389 of 2,602 (equivalent to 18% of all eligible providers in the study) cases while recommending a test for Rifampicin resistance--one of the main anti-TB drugs--in 108 of 2,602 cases (equivalent to 2% of all eligible providers in the study), the study found.

The authors did not find any typical alternate pattern of treating patients, such as one that might be an outcome of urban pollution. For instance, doctors might provide symptomatic relief for a patient’s cough in a place marked with high pollution, instead of suspecting TB.

Connecting patients with high quality doctors, awareness on correct antibiotic use could improve TB care

“The quality of TB care in urban India is highly varied--there are some providers who get every case wrong, but there are also those who are providing excellent care. It is key to connect patients with the doctors who provide excellent care,” Das said.  

High patient loads were not responsible for low quality care, as “of the 2,602 interactions, 45% had no other patients waiting, 65% had a queue of 1 or fewer, 75% had 2 or fewer, and 95% had 10 or fewer,” the study found.

Quality deficits were not driven by either knowledge gaps or financial incentives alone, the authors of the study wrote, adding that the incorrect handling of cases is a combination of both. The authors found that if a doctor was given more proof of a TB diagnosis such as a sputum report, the doctors were more likely to provide better quality of care, showing a lack of knowledge.

But, at the same time, the quality of diagnosis did not improve in all cases where test results were provided, and had little effect in reducing inappropriate medicine use, suggesting that increased awareness would not completely solve the problem.

“There is a lot of scope of improving the standards of care in the private sector,” said Yatin Dholakia, honorary secretary and technical advisor to the Maharashtra state anti-TB association. Associations such as the Indian Medical Association, the association of chest physicians in India, association of AYUSH doctors, medical colleges, should provide structured training to doctors, Dholakia said. He also suggested trainings be organised through non-governmental organisations in partnership with Mumbai’s municipal corporation because such sessions organised by the government alone often have limited response.

Use of fluoroquinolones and steroids, which were found to be common practices in the study, can be extremely harmful, and greater awareness around that could reduce their use, Das, one of the lead authors of the study suggested.

As the private sector engagement programme in Mumbai and Patna scaled up, more private doctors registered TB cases with the government, and recommended microbiological tests, suggesting that such programmes could help improve diagnosis and care, said Das.

The results of the programme should be studied in detail to understand how the standard of care has changed over the past four years since this study was conducted, said Dholakia, which could guide future interventions to improve the quality of care.

Registering more cases with the government could help. Still, in the public sector too, success of treatment is not as high as the government numbers would suggest, as we reported in November 2016. Only 73% of one kind of TB cases registered for treatment were successfully treated, much lower than the government-reported 84% success rate, according the study published in the United States and United Kingdom-based health journal Plos Medicine.

(Shreya is a writer and editor with IndiaSpend.)

We welcome feedback. Please write to respond@indiaspend.org. We reserve the right to edit responses for language and grammar.