India made notification of TB patients mandatory in 2012 to address the problem of delayed diagnosis, suboptimal quality of care, incorrect diagnostic and treatment protocols being used, and a high drop-out rate in the private sector. A year later, only 2% of all notified patients were from the private sector. Thanks to several initiatives adopted by the National TB Elimination Programme (NTEP), the proportion of notified cases has increased substantially — 21% in 2017, 25% in 2018, 28% in 2019, 31% in 2020, 32% in 2021, and 30% in 2022.
Despite the significant increase in the private sector TB notifications over the years, they fall far short of the targets set by the National Strategic Plan 2020-2025. The TB notification target set by NSP for the private sector in 2020 was 35%, 45% in 2021, and 56% in 2022. If the gap between what was achieved vis-a-vis what was targeted in 2020 was small, the shortfall increased by 13% in 2021 and a staggering 26% in 2022.
According to the target set by NSP, in 2022, there should have been 1.93 million TB notifications by the private sector. Yet, there were only 0.73 million notifications. A staggering 1.2 million TB cases in the private sector were missed in 2022. Even the NTEP’s target for expected notification in 2022 by the private sector was 0.95 million. What was actually achieved was only 0.73 million (77%). In contrast, the notification achieved by the public sector was 92.4% (1.68 million) of the expected notifications.
Based on the 2016 TB incidence of 2.8 million cases in India, of which only 0.3 million from the private sector and 1.6 million from the public sector were notified, WHO noted: “A staggering one million TB cases are missing from notification, most of them being diagnosed and treated in the private sector. That’s what makes the engagement with the private sector so very vital.” The National Strategic Plan also makes the same point about the missing cases in the private sector: “Hundreds of thousands of people with TB disease remain missing to TB surveillance/notification and services, and are likely in private health delivery systems or the community.” It had recommended that private provider engagement be rapidly scaled-up to “find and successfully treat two million patients in 2020-2021”.
While the National TB Prevalence Survey India (2019-2021) found 50% of TB patients sought care in the private sector, the National Strategic Plan says about 70% of the TB patients seek care in the private sector. While the TB prevalence survey found that 63.6% did not seek care for their symptoms, many of those who sought care in the private sector were not notified. According to the National Strategic Plan, “close to 0.54 million TB patients remain uncaptured by TB surveillance/notification and services, and are likely in private health delivery systems or the community”.
Based on the analysis of anti-TB drug sales by pharmacists in India, the private sector was estimated to have treated 2.2 million TB patients in 2014 alone. However, the notifications by the private sector in 2014 were just 0.1 million. “While it is unknown how many of the patients studied were over-diagnosed, there are concerns that the true incidence may be much higher than has been estimated,” says the National Strategic Plan.
The TB prevalence survey provided the much-needed information about the TB burden. It found that TB prevalence across all age groups was 312 per 100,000 population for the year 2021. In contrast, the case notification rate in 2021 (public and private sectors together) was only 153 per 100,000, as per the India TB report 2022; it was 172.1 per 100,000 in 2022.
