India’s private sector needs to take greater role in tuberculosis care

BMJ 2016; 354 doi: (Published 02 September 2016) Cite this as: BMJ 2016;354:i4774
  1. Sanjeet Bagcchi
  1. Kolkata

India’s private medical sector needs to get more involved in the management and control of tuberculosis, researchers reporting in two new studies in Lancet Infectious Diseases have said.1 2

The first study, led by Nimalan Arinaminpathy, senior lecturer at the Department of Infectious Disease Epidemiology, Imperial College London, considered the sales of 189 antituberculosis drugs in India during 2013-14 to calculate the number of patients who were treated in the private sector in that period. It estimated that the number of cases of tuberculosis treated in the private sector in 2014 was 2.2 million, more than double the currently estimated number of cases in that sector.

In 2014 6.3 million cases of tuberculosis were reported to the World Health Organization, with India reporting over a quarter of those cases—the largest proportion.

A news release by Imperial College London said, “Previous estimates pegged India’s total burden of TB [tuberculosis] at 2.2 million. However, this study estimates that over 2 million cases of TB were treated by India’s private sector alone, and an additional 1.4 million were managed in the public system, in 2014.”3

The researchers urged that to combat India’s situation regarding tuberculosis, “there is a re-doubled need to address this burden and to strengthen surveillance.”1

The second study, undertaken by Srinath Satyanarayana of McGill University in Montreal, and colleagues, found that Indian pharmacies often provided antibiotics to patients who seemed to have tuberculosis symptoms but that they rarely referred these patients to doctors, contributing to the delay in tuberculosis diagnosis.

The researchers examined 622 pharmacies in three Indian cities: Delhi, Mumbai, and Patna. They found that just 13% of pharmacies (80 of 599) (95% confidence interval 11% to 16%) managed patients with tuberculosis symptoms for two to three weeks “ideally” (defined as referrals without the use of antibiotics or steroids), while 62% (372 of 601) (58% to 66%) managed patients with confirmed tuberculosis diagnosis ideally.2

The researchers noted, “Our findings suggest that non-adherence to regulatory standards is higher when the patient’s condition is unknown, and that pharmacies prefer to treat in such cases rather than refer the patient to appropriate care. These findings can inform interventions to engage pharmacies in tuberculosis control and antimicrobial stewardship.”

Arinaminpathy told The BMJ, “We’ve known for a while that there is a large tuberculosis burden being managed by the private healthcare sector in India, but so far we’ve not had a concrete idea of the real scale of the challenge.”

Madhukar Pai, an author of the second study and associate director of the McGill International TB Centre in Montreal, said that both studies have highlighted the critical importance of engaging India’s massive private sector in improving tuberculosis care and control in the country.

He said, “A huge number of tuberculosis patients in India are seeking care in the private sector, and we need to do a better job of engaging private providers and working with them to improve quality of tuberculosis care. For example, pharmacists can be engaged to identify persons with classic tuberculosis symptoms and get them linked to care.”


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