Quality of tuberculosis care in India: a systematic review.

WITH AN ESTIMATED ANNUAL incidence of 2.0–2.3 million tuberculosis (TB) cases and about 150 000–350 000 deaths per year, India has the highest TB burden in the world.1 TB control depends on early diagnosis of pulmonary TB cases and their treatment with a full course of anti-tuberculosis drugs.2 For early diagnosis of TB, all persons with cough of ⩾2 weeks should be referred for TB evaluation.3 Correct treatment requires the use of standardised drug regimens recommended by the World Health Organization (WHO),2 the International Standards for TB Care (ISTC) and the Standards for TB Care in India (STCI).2–4 A recent systematic review showed that in India there is a delay of nearly 2 months in making a diagnosis of TB; patients are seen by on average three different providers before a diagnosis is made.5 Drug prescription analyses have shown that irrational and inappropriate anti-tuberculosis drug regimens are widely used.6 These studies suggest that the quality of TB care in India is a matter of concern.7 The Indian health care delivery landscape is complex and fragmented, with many types of care providers in the public and private sectors.8 Studies suggest that 80% of the first-contact health care and nearly 50% of TB care occurs in the private sector.9 The private sector is also very fragmented, with both unqualified (i.e., no formal medical degree) and qualified providers (a formal degree in either allopathic medicine or in alternative traditions such as Ayurveda, Unani, Siddha and Homeopathy [AYUSH]).10,11 A recent study of 100 villages in rural Madhya Pradesh found that, among primary care providers identifying themselves as ‘doctors’, 65% reported having no formal medical training, while 25% had AYUSH degrees, and only 10% reported having an MBBS (Bachelor of Medicine, Bachelor of Surgery, i.e., formal allopathic medicine) degree. The quality of medical care was highly variable, and was found to be deficient on many levels.12,13 While several studies in India have investigated different aspects of health care providers’ knowledge and practices related to TB diagnosis and treatment, this literature has not been systematically reviewed or benchmarked against international standards.