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Suboptimal TB care in India may hinder goal of TB elimination by 2025
India has announced ambitions to eliminate tuberculosis by 2025, however, deficits in care delivered by private practitioners may be hindering these efforts, researchers found.
“India has the highest burden of TB in the world,” Madhukar Pai, MD, PhD, director of the McGill Global Health Programs and McGill International TB Centre at McGill University in Montreal, told Infectious Disease News. “In 2017, an estimated 2.7 million people developed TB disease, and over 400,000 people died. So, India accounts for 27% of the global estimated cases and 25% of the estimated deaths.
“In India, the private health sector dominates the landscape — most Indians seek private health care. So, without engaging the private sector, India cannot end the TB epidemic. To work better with the private sector, we need to first understand how private care providers manage TB so we can improve the quality of TB care.”
To assess TB care, Pai and colleagues enlisted 24 adult actors and trained them to portray four different TB case scenarios during unannounced visits. Between November 2014 and August 2015, the “patients” had 2,652 interactions across 1,203 health care facilities with private care providers.
According to the researchers, correct management was observed in only 959 of 2,602 interactions included in the analysis benchmarked against national and international standards, primarily from referrals and ordering chest radiographs. Unnecessary medicines were given to almost all of the participants and antibiotic use was common, they reported. The researchers also noted that anti-TB drugs were prescribed in 118 of the patient-provider interactions, of which only 45 were given in instances when such treatment is considered correct.
“Also, providers delivered idiosyncratically consistent care, repeating all observed actions, including mistakes, approximately 75% of the time,” Pai and colleagues wrote.
Additionally, there was not a widely adopted common practice among the care providers, exposing the participants to a wide range of observed quality and various treatment protocols.
“Despite overall poor quality of TB care, we found a few positive findings,” Pai said. “First, [practitioners of Western medicine] with Bachelor of Medicine, Bachelor of Surgery (MBBS) degrees or higher were far more likely to correctly manage cases than informal or alternative health providers. Second, there was near-zero use of anti-TB drugs among non-MBBS providers. In general, these drugs were judiciously used with the correct regimen and dosage in all but five of 118 cases. Finally, 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 program.”
According to Pai, the results show that merely engaging private sector providers and focusing on TB coverage is not enough to eliminate TB in India.
“We need to work to improve the quality of TB care they deliver to patients,” Pai said. “Engaging [practitioners of Western medicine], ensuring a referral chain that leads patients to these providers, and linking their patients to free TB drugs and other subsidies in the public sector could be a useful strategy for India.” – by Caitlyn Stulpin
Disclosures: The authors report no relevant financial disclosures.