The government recently passed a gazette notification making the non-reporting of tuberculosis (TB) cases a punishable offence, with even a jail term of up to two years. The move comes against the backdrop of the Prime Minister’s call to end TB in India by 2025, ushering in a ‘mission mode’ approach to defeat the disease.
Even though the government made the notification of TB cases mandatory by all health-care providers in 2012, the TB programme continues to face the challenge of under-reporting of cases from the private sector, which caters to a majority of cases. A study in The Lancet in 2016 estimated that as many as 22 lakh cases of TB were treated in the private sector in 2014; in the public sector, the figure was 14 lakh. Despite efforts in the past decade to encourage higher case notifications, the private sector reported just over three lakh cases in 2016. Going by The Lancet ’s estimates, almost 19 lakh cases are still ‘missing’, a term used to define the gap between the estimated cases in the private sector and those reported to the government.
Now the question is this: what is the harm if a patient is not reported to the government and is being diagnosed and treated in the private sector? The answer may lie in the complex nature of the disease itself and the mostly unregulated nature of dealing with TB in the private sector. First, not being reported to the government means the true burden of the disease remains unknown. What cannot be measured, therefore, cannot be improved upon. Second, the absence of drug distribution controls and poor treatment practices accentuate the emergence of drug-resistant TB. Anti-TB drugs are widely available without prescription at numerous pharmacy outlets. Also, limited usage of the Standards for TB Care in India (STCI), which are the standard protocols to be adhered by providers, leads to incorrect diagnosis and improper treatment. This in turn delays the commencement of treatment and can even contribute to drug resistance. Finally, TB is five times more common among the economically weaker sections of society and the disease can have devastating financial and social consequences. In order to address these issues, the government has proposed innovative measures which include a ‘direct benefit transfer’ for nutritional support and free diagnosis and treatment, particularly to patients being treated in the private sector. However, the first step in extending these support systems to all patients would be to correctly identify them. It is here that the notification law can play a major role. (Considering how it has become quite common for people to go to chemists to seek easy over-the-counter treatment, involving chemist shops in the notification process was important, as was the inclusion of promoting self-notification.)
While the step to encourage greater notifications is commendable, it is vital to streamline and simplify the reporting process. A web-based application called ‘Nikshay’ was launched in 2012 to help providers notify cases to the authorities. However, low awareness about this portal among private providers and technical difficulties in the software resulted in its low use. Considering that punitive action can be taken against providers for not reporting cases, it is imperative that the reporting process itself becomes more accessible.
Moreover, it is important that private providers are actively engaged for better adherence to the STCI. While the notification law can improve case reporting, it doesn’t guarantee improved standards of care. In the past few years, several private sector engagement models that have been implemented in the country have significantly improved the quality of care. By assessing their feasibility, similar models need to be scaled up across the country. Collaboration with forums such as the Indian Medical Association should also be explored to conduct sensitisation workshops to improve knowledge among private providers.
Thus, the notification policy, supplemented by the comprehensive strengthening of the public health system, greater engagement with the private sector, the simplification of the reporting process and more awareness among public and health-care providers, is sure to reach the goal of a TB-free India.
Virander Singh Chauhan is former Director, International Centre for Genetic Engineering and Biotechnology. Pinky Anand is Additional Solicitor General of India