Private practitioners in India are delivering a wide range of largely inadequate care to TB patients, says a new study in PLoS Medicine. The study, carried out in Mumbai and Patna, also found vast variation and significant deficits in tuberculosis care.
The findings are significant as they come ahead of the United Nations General Assembly’s first high-level meeting on September 26 that will focus on stepping up efforts to end TB.
Dr Madhukar Pai, director of the McGill International TB Centre, along with Ada Kwan, a PhD student at the University of California at Berkeley, Benjamin Daniels and Dr Jishnu Das from the World Bank, and other colleagues, utilised 24 standardised patients (SPs) — seemingly healthy actors trained to portray four different tuberculosis case scenarios during unannounced visits — to assess management and quality outcomes of private providers.
The results revealed that only a third of the standardised patients got managed correctly, and qualified doctors did a much better job than informal or alternative providers.
“The results were not that good,” Pai told The Indian Express via e-mail.
A total of 2,652 standardised patient-provider interactions were analysed across 473 providers in Patna and 730 providers in Mumbai. Providers correctly managed SP cases, in adherence to national and international standards, in only 949 interactions, found the study. In the other cases, providers often stuck to the same erroneous protocols, repeating their own observed actions 75 per cent of the time in a second visit by a different patient. However, there was no single and widely-adopted “common practice” among providers and SPs encountered a wide range of observed quality and various treatment protocols.
“There were also several positive findings,” said Pai. Researchers found that allopathic providers with Bachelor of Medicine, Bachelor of Surgery degrees or higher were far more likely to correctly manage cases than non-MBBS providers. They found that anti-TB drugs were used judiciously, with the correct regimen and dosage, in most cases.
Providers who were presented with more diagnostic information by the patient offered better care, even if it meant referring their patients to the public-sector TB programme, found the study.
India accounts for a quarter of the world’s estimated 10.4 million new TB cases per year. It also accounts for nearly a third of 1.7 million deaths annually and a third of the estimated four million missing patients, who are either not diagnosed or not reported in national TB programmes. The private sector provides the bulk of primary health care in the country, serving as the first point of contact for 50 to 70 per cent of patients with TB symptoms, and prescribes nearly twice the amount of anti-TB drugs than in the public sector.
The Centre has also prioritised engaging the private sector in the national strategic plan for TB elimination.
“It is crucial for India to work with private health sector and make sure they are doing a good job of managing TB,” said Pai.
To reach its goal of eliminating TB by 2025, the Union Ministry of Health and Family Welfare’s Central TB Division has tied up with several partners in 400 cities to support private practitioners treating TB patients. “We have intensified our engagement and while over 1.5 lakh private doctors are registered with the TB national programme, we have 25,000 regularly reporting TB cases,” said a highly-placed official.