Abstract
SummaryBackgroundUnderstanding the amount of tuberculosis managed by the private sector in India is crucial to understanding the true burden of the disease in the country, and thus globally. In the absence of quality surveillance data on privately treated patients, commercial drug sales data offer an empirical foundation for disease burden estimation.MethodsWe used a large, nationally representative commercial dataset on sales of 189 anti-tuberculosis products available in India to calculate the amount of anti-tuberculosis treatment in the private sector in 2013–14. We corrected estimates using validation studies that audited prescriptions against tuberculosis diagnosis, and estimated uncertainty using Monte Carlo simulation. To address implications for numbers of patients with tuberculosis, we explored varying assumptions for average duration of tuberculosis treatment and accuracy of private diagnosis.FindingsThere were 17·793 million patient-months (95% credible interval 16·709 million to 19·841 million) of anti-tuberculosis treatment in the private sector in 2014, twice as many as the public sector. If 40–60% of private-sector tuberculosis diagnoses are correct, and if private-sector tuberculosis treatment lasts on average 2–6 months, this implies that 1·19–5·34 million tuberculosis cases were treated in the private sector in 2014 alone. The midpoint of these ranges yields an estimate of 2·2 million cases, two to three times higher than currently assumed.InterpretationIndia's private sector is treating an enormous number of patients for tuberculosis, appreciably higher than has been previously recognised. Accordingly, there is a re-doubled need to address this burden and to strengthen surveillance. Tuberculosis burden estimates in India and worldwide require revision.FundingBill & Melinda Gates Foundation.
Highlights
Tuberculosis is a major global public health challenge.[1]
Standardised tuberculosis treatment in India is delivered by the public sector through the Revised National TB Control Programme (RNTCP), early diagnosis and treatment are hampered by the presence of a vast and unregulated private health-care sector.[2,3,4,5]
In the present study, using corresponding data for 2013 and 2014, we explored systematically the implications for tuberculosis burden being managed by the private sector in India, and compared this burden directly against that managed by the public sector
Summary
Tuberculosis is a major global public health challenge.[1]. In 2014, 6·3 million cases of tuberculosis worldwide were reported to WHO, with India accounting for over a quarter of these cases, the highest of any country.[1]. Estimating the numbers of patients being treated in the private sector is important for several reasons: it provides information about the performance of a public system in detecting tuberculosis cases, while helping in planning for government intervention in the private sector.[8] Overall, it is crucial to know the scale of the problem: the undetected burden that exists outside the public health system. With a lack of systematic data on the private sector, arriving at these estimates has proven difficult.[9] Instead, alternative approaches—such as that used by WHO—draw from expert opinion on the proportion of cases that are detected by the public sector
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