Data suggests up to 40 to 50 percent of tuberculosis (TB) patients are likely to be accessing healthcare services in private sector. A study done in Lucknow by Dr Rajendra Prasad, former Professor and Head of Pulmonary Medicine, King George's Medical University (KGMU), showed 44 different prescriptions from physicians for the same TB patient -- this is when TB treatment should have been the same in private and public sector both because International Standards for TB care (ISTC) guidelines have been there since 2005 onward.
Standards for TB Care in India (STCI) guidelines were released on World TB Day (24 March 2014) in New Delhi. Dr Madhukar Pai, Associate Director, McGill International TB Centre, called upon private- and public-sector physicians and other healthcare providers to follow these guidelines. He was addressing private physicians in Lucknow in a continuing medical education (CME) programme organized in Lucknow by UP State TB Cell and partners.
Dr Pai said to Citizen News Service (CNS) that diagnosis continues to be a weak aspect of TB control as out of the three million missing TB cases globally, one million are from India. He said that we do not know whether they are un-diagnosed or they are not noticed by our health system.
Dr Pai highlighted that "When people go first to the pub lic sector for TB care, the challenge is, they almost never get tested for drug resistance because the programme [Revised National TB Control Programme - RNTCP] is mainly based on sputum microscopy for TB diagnosis. Only when they fail treatment or they have TB relapse, they get tested for anti-TB drug resistance, which is probably too late. In the private sector, there are also reports of irrational medical practices [in diagnosing and treating TB both]. For a long time the private sector has been relying on inaccurate [serological] blood test for TB [which is now banned by the Government of India notification issued in June 2012 as well as WHO had also recommended against using blood serological tests for TB diagnosis]. Since now blood serological tests are gone, private sector needs to start using good WHO-recommended tests for accurate TB diagnosis such as LED microscopy, Gene Xpert, Line Probe Assays (LPAs) and Liquid and Solid Cultures."
But these WHO-recommended accurate tests for TB are also very expensive in private sector although available for free in public sector. "So bringing down the cost and making it affordable is one step toward improving diagnosis in private sector. IPAQT initiative is now a coalition of more than 60 accredited private laboratories across India that are offering Gene Xpert, LPAs and Liquid Cultures for prices that are almost half of the market prices," said Dr Pai. Public sector is obviously keen to get notification from the private side, which is probably not happening much anywhere in India [Although TB was declared as a notifiable disease in May 2012 but very few private-sector healthcare providers have notified TB since then]. So increasing TB notification and linking them to accessing free multidrug-resistant TB (MDR-TB) care in the public sector for people who cannot afford private care, are other positive outcomes of this IPAQT initiative, said Dr Pai.
Central TB Division, Government of India, has released the first edition of Standards for TB Care in India (STCI) on 24th March 2014. Dr Pai strongly recommended that public- and private-sector healthcare providers should follow STCI for uniform TB-care services across the board. STCI will also address irrational use of TB medicines if rolled out well. "It is absolutely critical for all Indian physicians to follow the same standards while providing TB care to improve cure rate and avoid the development of drug resistance," said Dr Pai.
Dr Pai wholly supported the recent move by the government to stop sale of anti-TB medicines along with other 45 antibiotics without medical prescription from 1st March 2014 onward. "It is worrisome that drugs for TB were indiscriminately used and available over the counter [without medical prescription]. Market data suggests that there is so much anti-TB-drug consumption in India [more than that the number of TB cases], which clearly means that there is indiscriminate use of anti-TB drugs going on. Also there are reports that chemists often act like doctors and give antibiotics by themselves. That is why I think this regulation was very much needed especially for higher generation of antibiotics. Anti-TB drugs are very powerful drugs and must not be given without prescription. TB drugs have to be given by qualified doctors," said Dr Pai.
Rahul Kumar Dwivedi, CNS
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