From Where Are Tuberculosis Patients Accessing Treatment in India? Results from a Cross-Sectional Community Based Survey of 30 Districts

Abstract

BackgroundTuberculosis (TB) notification in India by the Revised National TB Control Programme (RNTCP) provides information on TB patients registered for treatment from the programme. There is limited information about the proportion of patients treated for TB outside RNTCP and where these patients access their treatment.ObjectivesTo estimate the proportion of patients accessing TB treatment outside the RNTCP and to identify their basic demographic characteristics.MethodsA cross sectional community-based survey in 30 districts. Patients were identified through a door-to-door survey and interviewed using a semi-structured questionnaire.ResultsOf the estimated 75,000 households enumerated, 73,249 households (97.6%) were visited. Of the 371,174 household members, 761 TB patients were identified (∼205 cases per 100,000 populations). Data were collected from 609 (80%) TB patients of which 331 [54% (95% CI: 42–66%)] were determined to be taking treatment ‘under DOTS/RNTCP’. The remaining 278 [46% (95% CI: 34–57%)] were on treatment from ‘outside DOTS/RNTCP’ sources and hence were unlikely to be part of the TB notification system. Patients who were accessing treatment from ‘outside DOTS/RNTCP’ were more likely to be patients from rural areas [adjusted Odds Ratio (aOR) 2.5, 95% CI (1.2–5.3)] and whose TB was diagnosed in a non-government health facility (aOR 14.0, 95% CI 7.9–24.9).ConclusionsThis community-based survey found that nearly half of self-reported TB patients were missed by TB notification system in these districts. The study highlights the need for 1) Reviewing and revising the scope of the TB notification system, 2) Strengthening and monitoring health care delivery systems with periodic assessment of the reach and utilisation of the RNTCP services especially among rural communities, 3) Advocacy, communication and social mobilisation activities focused at rural communities with low household incomes and 4) Inclusive involvement of all health-care providers, especially providers of poor rural communities.

Catastrophic costs of tuberculosis care: a mixed methods study from Puducherry, India

“…Patients were unaware and not informed by providers about the possibility of TB as a diagnosis for their symptoms. As previously reported [17], there was a preference of private providers. In India, there is large prevalence of private providers, and the healthcare costs in private care are higher than in the public sector [17,18].…”

“…As previously reported [17], there was a preference of private providers. In India, there is large prevalence of private providers, and the healthcare costs in private care are higher than in the public sector [17,18]. Qualitative interviews revealed that a lack of awareness of TB care service availability in the public sector combined with a lack of awareness about TB symptoms, in the underlying milieu of general preference for private facility, the factors including timings of service availability, perception of quality, etc., could have led to this phenomenon of a higher proportion of participants seeking private-sector care.…”

“…Besides distance from healthcare facilities and poor connectivity, rural labor is not irreplaceable, and paid leave is not available, thus making them incur heavy indirect costs due to loss of wages and less productivity. Rural people have also been known to access treatment ‘outside DOTS/NTP’ more often than their urban counterparts [17]. …”

Operational research within a Global Fund supported tuberculosis project in India: why, how and its contribution towards change in policy and practice

“…A subset of the data from these surveys was used to answer some specific research questions that were operationally relevant. These studies were written-up as separate manuscripts (n = 6) and published in peer-reviewed journals [13–18]. The findings were also presented at The Union’s World Conferences on Lung Health (years 2011–2016).…”

“…A publication from the baseline knowledge, attitude and practice survey showed that nearly half of the TB patients in the community were being treated in the private sector, outside the RNTCP notification system [13]. The quality of TB care in the vast un-regulated private sector was largely unknown.…”