Abstract
In India, the country with the world’s largest burden of tuberculosis (TB), most patients first seek care in the private healthcare sector, which is fragmented and unregulated. Ongoing initiatives are demonstrating effective approaches for engaging with this sector, and form a central part of India’s recent National Strategic Plan: here we aimed to address their potential impact on TB transmission in urban settings, when taken to scale. We developed a mathematical model of TB transmission dynamics, calibrated to urban populations in Mumbai and Patna, two major cities in India where pilot interventions are currently ongoing. We found that, when taken to sufficient scale to capture 75% of patient-provider interactions, the intervention could reduce incidence by upto 21.3% (95% Bayesian credible interval (CrI) 13.0–32.5%) and 15.8% (95% CrI 7.8–28.2%) in Mumbai and Patna respectively, between 2018 and 2025. There is a stronger impact on TB mortality, with a reduction of up to 38.1% (95% CrI 20.0–55.1%) in the example of Mumbai. The incidence impact of this intervention alone may be limited by the amount of transmission that has already occurred by the time a patient first presents for care: model estimates suggest an initial patient delay of 4–5 months before first seeking care, followed by a diagnostic delay of 1–2 months before ultimately initiating TB treatment. Our results suggest that the transmission impact of such interventions could be maximised by additional measures to encourage early uptake of TB services.
Highlights
India has the world’s largest burden of tuberculosis (TB)[1]
In a demonstration of private sector engagement in India, the ‘Public Private Support Agency’ (PPSA) model used a combination of patient subsidies and provider incentives to encourage higher standards of diagnosis and treatment amongst private providers[17]
While Patna is typical of an urban setting in India, Mumbai is exceptional in its high burden of MDR-TB18,19
Summary
India has the world’s largest burden of tuberculosis (TB)[1]. Over the past two decades India’s Revised National Tuberculosis Control Programme (RNTCP) has made notable progress in reducing TB deaths, through the provision of basic TB services via the public sector[2,3,4,5]. Tuberculosis was made a notifiable disease in 201213, there remain major challenges in encouraging private providers to comply with these obligations[14,15] For these reasons, in India’s recently-announced plan to eliminate TB, private sector engagement forms a key strategic priority[16]. Implemented in two Indian cities, Mumbai and Patna (respectively by the NGOs PATH and World Health Partners), these measures have yielded rapid increase in TB notification from the private sector[3] Their potential epidemiological impact remains unclear; measuring such impact empirically presents prohibitive challenges in the intervention coverage, population size and study duration that would be needed. We present results for the potential epidemiological impact of private sector engagement in Mumbai and in Patna, followed by an examination of the drivers of this impact: in particular, we investigate specific types of patient and provider behaviour that matter most for TB transmission. We discuss implications for controlling TB transmission in India, and important questions arising for future work
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