Tuberculosis: a private and public health and data mix
Authors: Peter Byass
Journal: The Lancet Infectious Diseases (2016)

The clue in the title lies in the phrase public health. Data for understanding the health status of communities and nations comprise a fundamental public good.1Rolnick J Aggregate health data in the United States: steps toward a public good.Health Informatics J. 2013; 19: 137-151Crossref PubMed Scopus (10) Google Scholar Public health data can only be captured and curated effectively if sufficient resources and determination are deployed for the purpose. But, from private sector perspectives of profits and shareholders, it might seem entirely reasonable not to prioritise the collection of public health data. In The Lancet Infectious Diseases, Nimalan Arinaminpathy and colleagues2Arinaminpathy N Batra D Khaparde S et al.The number of privately treated tuberculosis cases in India: an estimation from drug sales data.Lancet Infect Dis. 2016; (published online Aug 24.)http://dx.doi.org/10.1016/S1473-3099(16)30259-6Google Scholar tackle a specific manifestation of this public–private dichotomy in examining the complex mix of tuberculosis treatment uptake in India. India is a country where health services are undergoing a rapid transition from the former domination of the government sector into a public–private plurality. In a country of over 1 billion people, with huge socioeconomic inequities, this plurality of health services is likely to persist for a long time. Managing infectious diseases associated with poverty, like tuberculosis, would traditionally have been regarded as a governmental responsibility. The new findings suggest that about two-thirds of tuberculosis treatment in India is now being delivered by the private sector. How can that important private sector input best be monitored? The USA, with arguably the world's largest private-dominated health-care system, provides an interesting comparison. The Centers for Disease Control and Prevention, as the national health protection agency, carries responsibility for documenting tuberculosis (which has long been a nationally notifiable disease), in the form of an annual report.3Centers for Disease ControlReported tuberculosis in the United States, 2014. US Department of Health and Human Services, Centers for Disease Control, Atlanta, GA2015Google Scholar Nevertheless, as in India, delivery of tuberculosis treatment is a public–private mix, with a quarter of clinical care for tuberculosis delivered through the private sector.4Balaban V Marks SM Etkind SC et al.Tuberculosis elimination efforts in the United States in the era of insurance expansion and the Affordable Care Act.Public Health Rep. 2015; 130: 349-354Crossref PubMed Scopus (18) Google Scholar One has to assume in the USA that the procedures required of the private sector for notifying tuberculosis cases to the public authorities are sufficiently robust and well-enforced. India only made tuberculosis a notifiable disease in 2012, following reports of multiple drug-resistant disease.5Gawde N Do we need notification of tuberculosis? A public health perspective.Indian J Med Ethics. 2013; 10: 56-58PubMed Google Scholar To what extent mandatory reporting has facilitated the extraction of reliable data from the private sector is uncertain, particularly given that half of private practitioners in a survey cited lack of time as a reason for failing to notify tuberculosis cases in Chennai.6Thomas BE Velayutham B Thiruvengadam K et al.Perceptions of private medical practitioners on tuberculosis notification: a study from Chennai, South India.PLoS ONE. 2016; 11: e0147579Google Scholar The compliance of the Indian private health sector in terms of notifying tuberculosis (and possibly other diseases) thus seems to be a major obstacle to gathering public health data. Alternative and less direct approaches are therefore important for reaching any realistic national picture of tuberculosis treatment in India, where a substantial proportion of worldwide cases occur.7Cowling K Dandona R Dandona L Improving the estimation of the tuberculosis burden in India.Bull World Health Organ. 2014; 92: 817-825Crossref PubMed Scopus (19) Google Scholar But are such indirect methods appropriate and relevant? Arinaminpathy and colleagues2Arinaminpathy N Batra D Khaparde S et al.The number of privately treated tuberculosis cases in India: an estimation from drug sales data.Lancet Infect Dis. 2016; (published online Aug 24.)http://dx.doi.org/10.1016/S1473-3099(16)30259-6Google Scholar chose to move their focus upstream from data at the patient-provider level to drug supply statistics. Since there is no single drug uniquely and solely indicated for treating tuberculosis, this approach involved some fairly brave assumptions. Sales of drugs containing rifampicin were chosen as the key indicator on the basis of having fewer indications than other drugs for non-tuberculosis treatment. Patient-months of treatment had to be measured, since there were no direct data on individual treatment duration. The contribution of false-positive diagnoses of tuberculosis had to be considered. Putting everything into the pot, the public health burden of tuberculosis in India appears to be even higher than has often been assumed, thus representing a major challenge to both the public and private health sectors. The approach taken here seems to be useful, but is by no means equivalent to having the individual-level data one would wish for. In an era of global concern about tuberculosis, including HIV co-infection and multiple drug-resistant organisms, complacency about gathering tuberculosis treatment data and establishing the corresponding magnitude of public health burdens is not acceptable. An increasing number of countries with high tuberculosis burdens are also encountering growth in their private health sectors. Private sector involvement might not be a bad thing in itself, but mechanisms to extract reliable public health data from private health providers on tuberculosis and other diseases of public health concern are essential. Just as public health systems implicitly capture data as one of their intrinsic functions, public resources must be more effectively deployed for capturing and curating data of public interest from the private sector. I declare no competing interests. The number of privately treated tuberculosis cases in India: an estimation from drug sales dataIndia's private sector is treating an enormous number of patients for tuberculosis, appreciably higher than has been previously recognised. Accordingly, there is a re-doubled need to address this burden and to strengthen surveillance. Tuberculosis burden estimates in India and worldwide require revision. Full-Text PDF Open Access