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Response to Dr Daley's article: Do not ignore the private sector Radhika Banka a,*, Zarir Udwadia b a

DNB Trainee, Department of Pulmonary Medicine, P D Hinduja National Hospital and Medical Research Centre, Veer Savarkar Marg, Mahim, Mumbai 400016, India b Consultant, Department of Pulmonary Medicine, P D Hinduja National Hospital and Medical Research Centre, Veer Savarkar Marg, Mahim, Mumbai 400016, India

The review by Dr Daley1 provides an informative insight to the current MDR TB (Multi Drug Resistant Tuberculosis) scenario in India. However, official figures may not be representative of ground reality because large numbers of Tuberculosis patients choose to bypass the RNTCP (Revised National Tuberculosis Control Program), opting instead for care with private practitioners. These patients are slipping under the radar and in fact, scandalously, notification of Tuberculosis was only made compulsory after the first Totally Drug Resistant (TDR) TB Cases were reported in 2011.2 In a community based door to door survey conducted by Satyanarayan in thirty districts across the country, they found that nearly half of TB cases were on treatment from ‘outside DOTS/RNTCP’ sources and hence were missed by the TB notification system.3 Results from the National Family Health Survey-3 revealed that the private sector was the preferred source of healthcare (70% of urban households and 63% of rural households) for patients diagnosed with TB, although there is very variable quality of treatment provided by private practitioners.4 The WHO slogan for World TB Day on 24 March, 2014 was e ‘reach the missing three millions’. Out of the estimated three million incident TB cases missing from notification globally, nearly a million are from India. More than a third of the TB cases in the country are unable to avail the public health program services. Most of these missed cases might have been diagnosed and treated in other health care sectors, including the large private sector in India and these cases largely remain unnotified to the program.5 WHO has estimated that in 2009, 99,000 cases of MDR TB emerged in the country including those outside RNTCP.

Among these, 64,000 were estimated to have emerged from TB cases notified to RNTCP, which leaves almost a third of cases being notified outside RNTCP.6 Thus whilst we agree with the author that the RNTCP is a robust public health program which has reached out to over 15 million people in the last decade, the private sector cannot be wished away. The sheer number of Indian TB patients visiting private practitioners mandates the importance of Public Private Program Models. The dysfunctional relationship between private and public sectors is, in our opinion fuelling India's MDR-TB Crisis.7 Clearly the way ahead involves public-private mix (PPM) and currently apart from a few pilot studies such as the WHO Stop TB Partnership, involvement of NGOs, private practitioners, IMA (Indian Medical Association) and projects such as Akshya (Union) as a part of RNTCP for “universal coverage”, this has yet to be developed and expanded.8,9

Conflicts of interest All authors have none to declare.

Editor's note We definitely agree with the views expressed in the letter. Although RNTCP is making efforts to involve private sector by introduction of various schemes, lot more has to be done in this direction from private sector as well as by nongovernmental sector including private practitioners as their social responsibility.

* Corresponding author. Tel.: þ91 022 24447353, þ91 9869403861, þ91 9757262410. E-mail address: [email protected] (R. Banka). http://dx.doi.org/10.1016/j.ijtb.2015.02.029 0019-5707/© 2015 Tuberculosis Association of India. Published by Elsevier B.V. All rights reserved.

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1. Daley CL. Global scale-up of the programmatic management of multidrug-resistant tuberculosis. Indian J Tuberc. 2014;61:108e115. 2. Udwadia ZF, Amale RA, Ajbani KK, Rodrigues C. Totally drug-resistant tuberculosis in India. Clin Infect Dis. 2012;54: 579e581. 3. Ministry of Health and Family Welfare. National Family Health Survey (NFHS-3), 2005-06. Available from: http://www. measuredhs.com/pubs/pdf/SR128/SR128.pdf Last accessed from 21.06.14 4. Satyanarayana S, Nair SA, Chadha SS, et al. From where are tuberculosis patients accessing treatment in India? Results from a cross-sectional community based survey of 30 districts. PloS One. 2011;6:e24160. http://dx.doi.org/10.1371/ journal.pone.0024160. Epub 2011 Sep 2.


5. World Health Organisation. Message from WHO Representative to India; 2014. Available from: http://www.searo.who.int/india/ mediacentre/events/2014/tb_day/en/. Last accessed from 21.06.14. 6. Revised National Tuberculosis Control Programme. Guidelines on Programmatic Management of Drug Resistant TB (PMDT) in India. New Delhi: Central TB Division; 2012 [Chapter 1]: Background & Framework For Effective Control of Multi DrugResistant Tuberculosis 4 p. 7. Udwadia ZF, Pinto LM. Tuberculosis management by private practitioners in Mumbai, India: has anything changed in two decades? PloS One. 2010 Aug 9;5:e12023. http://dx.doi.org/ 10.1371/journal.pone.0012023. 8. World Health Organisation. Public-private Mix for TB Care and Control a Toolkit. Geneva: Stop TB Partnership; 2010. 9. TB India. Revised National TB Control Programme Annual Status Report. New Delhi: Central TB Division; 2013 [Chapter 9]: Partnership.

Response to Dr Daley's article: Do not ignore the private sector.

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