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Management of tuberculosis in India: time for a deeper dive into quality.

The diagnosis and treatment of tuberculosis (TB) remains a persistent challenge for health services in India. While the Revised National TB Control Programme (RNTCP) has announced 'universal access to quality TB diagnosis and treatment for all TB patients in the community' as its new goal in the new National Strategic Plan (2012– 17), 1 there seems to be no clear strategy to systematically measure and document the quality of TB care, in both public and private sectors. The continuing lack of such a strategy goes hand-in-hand with a narrative of 'blame', where every new TB crisis is predictably assigned to the actions of the private sector in India. It is time to move beyond assigning blame to systematically understanding the practices of diagnosis and treatment of TB among multiple healthcare providers in multiple settings. For instance, it is widely believed that how an average patient with TB gets diagnosed and treated in India depends entirely on where they seek care. If they go to the public sector, they will likely be diagnosed using sputum smears (which are known to have low sensitivity and cannot detect drug-resistance) and treated with a thrice-weekly, intermittent short-course regimen, and will likely have treatment supervision support. Their diagnosis and treatment will be free, but not necessarily convenient or accessible to all patients. Similarly, it is also believed that if patients go to the private sector, they will likely be diagnosed with just chest X-rays, or a combination of chest X-rays and a blood test (either an antibody serological test, or an interferon-γ release assay such as QuantiFERON-TB Gold; marketed in India as 'TB Gold'). 2,3 These patients will then be started on a variety of daily drug regimens with little or no supervision. 4,5 For them, diagnosis and treatment will not be free and most patients will pay out-of-pocket, regardless of how poor they are. 6 Of particular concern has been the overuse of blood-based tests for TB in the private health sector. 2,3 Sputum is the most important sample for diagnosis of pulmonary TB and every guideline recommends the use of sputum-based tests such as smears, culture and nucleic acid amplification tests. But, for several reasons, including poor regulation and financial incentives, blood is the most popular sample in the Indian private sector. 3 Blood-based antibody tests (e.g. IgG/IgM ELISA or rapid tests) and interferon-γ release assays (e.g. TB Gold) are inaccurate 7,8 and …