The medical practitioner has a major part to play in early diagnosis of pulmonary TB, thorough and systematic treatment of all detected cases till their disease is arrested, prevention of the spread of the disease by BCG vaccination to the uninfected, isoniazid chemoprophylaxis to all children below 5 years of age who are infected and to all adult contacts, health education of the people and finally in the rehabilitation of those who lose their jobs or require comparatively light work. He has to participate in this “Mahayagna” launched to eradicate TB from our land as speedily as possible.

The importance of GPs in various aspects of TB control is emphasised. The majority of patients who go to a State Clinic have typically been under care of a GP at one stage or another. In an urban clinic in Uttar Pradesh, an average of about 10-15% of patients are in the first stage, 20-30% in the second stage and 55-70% in the third stage of TB. These figures have held constant for the past 15 years. Given this scenario, it is considered that unless the co-operation between the clinic doctor and the GP improves, there could not be any improvement in these figures (which are similar to figures in the rural areas). The GP is equally important at the last stage of TB, when only he/ she can instill the necessary discipline in the patient to continue regular treatment. GPs can be useful in providing notification of TB, in regulating the sale and dispensation of anti-TB drugs, treating patients in domiciliary care, participating in mass radiography and contact exams. Several advantages that would accrue from a liaison between the clinic doctor and the GP are listed and it is suggested that registered Vaids and Hakims in rural areas be enlisted to help the Government.

Today, the role of the GP in the TB control programme has increased from only providing early diagnosis as in the past. The GPs, perhaps due to fear of losing a patient, typically show apathy in prompt and accurate diagnosis and there is inadequate treatment of diagnosed patients. The role of the NTI is explained to get an idea of how GPs could be involved in follow-up of treatment. While 105 teams of TB officers and staff of the District Clinic, Ahmedabad had been trained thus far by NTI at Bangalore, nearly half had not gone back to establish diagnostic centers in their districts, as expected. To include GPs effectively in the national TB efforts, it is necessary to integrate the control programme with the public health services as is done in Gujarat. Here, because the Public Health Services and the Medical Health Services functioned under one head, there was no problem in getting co-operation from the Medical Officer of the PHCs. Regarding GP training, offering GPs a general medical refresher course with a special part devoted to TB, issuing pamphlets periodically on the latest developments in TB control and providing training for GPs at the undergraduate and post-graduate levels in medical colleges are recommended actions. In teaching about TB, students should be taken to the TB Demonstration and Training Centers and emphasis should be on modern trends in the diagnosis and treatment, especially, at the community level. Some difficulties the GPs experienced in getting involved with the TB programme such as getting laboratory and X-ray exams for their patients are discussed. A voluntary body such as the TB Association could help by conducting post-graduate refresher courses, motivating defaulters and undertaking care and after-care work. Helping GPs update and expand their knowledge of TB, providing them with certain facilities will ensure their greater involvement in the NTP.

The editorial emphasises the need for GPs to be provided with adequate knowledge and training (a responsibility to be shared by universities, medical colleges, the central and state governments and others involved in the anti-TB programme) so that erroneous diagnosis, leading delayed referral and, misuse of drugs, by GPs, may be prevented. Suggestions to accomplish this objective include replacing mere clinical teaching with community-oriented teaching in urban and rural practice fields, where the practice of the NTCP can be demonstrated, giving priority, especially to rural GPs to attend symposia and various types of orientation courses and holding State TB conferences in the District Centers with the participation of GPs and other specialists. The NTCP has no concrete plan to enlist the GPs’ aid. The GPs could assist significantly by training qualified and popular practitioners in rural areas to hold TB Clinics, to refer cases and to manage these clinics without fear of losing the cases. Provision of proper record keeping schedules, facilities for X-ray and sputum examinations, if these cannot be arranged at the clinic itself, would encourage GPs to participate collaboratively with clinics so that the clinics could manage the diagnosis and treatment while the management of the cases including default actions could be the GPs’ responsibility. The TAI, with the IMA, could jointly develop a strategy for the active involvement of GPs in the NTCP and forward it to the Health Directorate for implementation, with their co-operation.

The panel included two GPs, an administrator and specialists in private practice and in government clinics and the Technical adviser of the TAI. The panel discussed the problem in great detail and the following is the consensus of the discussion.

The greatest challenge in the United States, today, is to prevent those persons who have already acquired a TB infection from developing the disease. Physicians play a critical role in meeting this challenge. The natural history of TB infection is illustrated and discussed. The least well-understood aspect of TB transmission is that of host susceptibility. Although the precise mechanisms underlying the reactivation of latent TB infection are not well-understood, there are certain clinical and epidemiological factors associated with the development of TB and these are listed along with some general strategies for TB prevention. In this regard, air-control measures such as urging patients to cover their noses and mouths when coughing, the provision of adequate ventilation in buildings, are helpful. Two approaches for providing direct protection to uninfected persons, vaccination and drug treatment or primary prophylaxis are discussed in detail. While isoniazid preventive therapy has been found to substantially reduce the risk of TB at a generally acceptable risk to the patient, for several listed reasons, this therapy is not universally applied in the US. Alternative drugs for those resistant to isoniazid, identification of candidates for preventive treatment, prescribing and management of isoniazid preventive therapy are elaborated. Consideration of the social aspects of TB and continuing the search for new, effective, preventive therapy regimens that can be delivered cheaply, safely and for relatively brief durations are recommended for future TB prevention.

This paper presents the findings of some of the first studies on the private sector in TB control in India, undertaken by the Foundation for Research in Community Health, in the rural and urban parts of Maharashtra. Two studies examined the management practices of private medical practitioners. One prospective study documented the treatment behaviour of TB patients under care of private medical practitioners and the third one evaluated two city-based TB projects undertaken by groups of private medical practitioners.

The Aga Khan University Hospital, in Karachi, Pakistan, is a 650-bed university teaching hospital. There is little data from Pakistan on the awareness and application of the WHO’s TB treatment guidelines among physicians. This study evaluates physician compliance with these guidelines. A questionnaire to measure physician compliance was developed, pilot tested and standardised. Case records of all patients hospitalized with TB were reviewed (January-December 1995, n = 229), and were classified into WHO Category 1(n = 191), Category 2 (n = 9) and Category 3 (n = 29).

A total of 53 (23%) patients had a diagnostic bacteriological sputum smear examination, of which 38% were smear positive and 47% culture positive. Of 25 cerebrospinal fluid cultures 12% were positive. No sputum smear tests were conducted during treatment. Of 58 patients in Category 1 who completed therapy 74% received a 2-month intensive phase consisting of HRZE (isoniazid, rifampicin, pyrazinamide, ethambutol) (n = 43), while 41% received a 6 month continuation phase with HE (n = 24). Over 70% patients were lost to follow up, more than half of these during the intensive phase.

The study reflects poor awareness of the WHO guidelines and low compliance among physicians, and a high loss to follow-up. Efforts are needed to create physician awareness about the WHO guidelines and their use. This study can be used to assess the effectiveness of any future physician education and to identify areas of weakness in health care.

The WHO and the IUATLD have recommended fixed dose combination (FDC) tablets containing Rifampicin for TB treatment. However, due to variation in bioavailability of the Rifampicin and quality of Rifampicin in FDCs have prevented their large scale use resulting in lower production and higher prices beyond affordability in developing countries. In this paper, the authors estimate the potential size of the market for Rifampicin containing FDCs assuming that all the currently marketed Rifampicin will be sold in FDCs. The quantity of Rifampicin is estimated by the following equations : the quality of Rifampicin per treatment regimen multiplied by the number of TB cases treated in public and private sector. The future size of the market for FDCs will be influenced by trends in numbers of cases, the ratio of cases treated in the public v/s the private sector and the ratio of cases not treated at all. The future trends of the TB epidemic may be influenced by several factors such as implementation of control strategy, commitment of government for TB control and the impact of the HIV epidemic. Hence, the authors have decided to provide an estimate of the present market.

WHO collected the information on the use of FDCs in public sector through a questionnaire; 85 countries representing about 90% of the world’s TB cases responded to the WHO questionnaire. About 50% of the 85 countries use Rifampicin as FDCs in the public sector, however most of these are small countries. In the public sector, an estimated 23.8% of the total number of notified TB cases are treated with two or three drug FDCs. In the public sector it is estimated that the global amount of Rifampicin used yearly to treat 3.57 million TB cases is 123.7 metric tons, representing 78.9% million tablets of 150 mg Rifampicin or 34 g per TB case. In the private sector, it is estimated that 2.54 million TB cases are treated using 99.9 metric tons, representing 666.3 million tablets of 150 mg Rifampicin or 39 g per case. Thus, the potential global market for the four drug FDC tablet (R-150 mg, H-75 mg, PZA-400 mg and Emb-75 mg) is 305 million tablets per year, 105 and 200 million of which would be distributed in the public and private sectors respectively. The uncertainty of the estimate remains considerable, as shown by the 90% confidence intervals. In conclusion, the study demonstrated a large potential global market for FDCs that should encourage pharmaceutical manufacturers to produce WHO recommended dosages of FDCs at affordable prices. Current use of Rifampicin in the FDCs is only 25% of the total Rifampicin used in the world.

The paper reviews current understanding of the behaviour and interactions of TB patients and private for-profit providers, as a precursor to devising interventions for field testing to win over the private practitioners and private voluntary organizations to the DOTS strategy. India is a vast and heterogeneous country. The location of the study sites are New Delhi, Agra, Jaipur, Lucknow, Morena, 24 Parganas, West Bengal, Wardha, Bombay, Pune, Tumkur, Madras, Bangalore, North-east which indicate that the available information is representative of the whole country. Even then specific local peculiarity cannot be excluded. The study period ranged from 1976 to 1996, most of them carried out in the 90s. In few instances, the evidence was supplemented by interviews with knowledgeable experts who had first hand information of the issues being discussed. The findings of the review report are as follows: The prevalence of TB is highest among male adults, belonging to low socio-economic strata and tribals. The general public was found to be reasonably aware of the symptoms of TB. Chest symptomatics are being found to be 5-10% of the general population. The process of health seeking behaviour of a TB patient is complex and may well last several years. Most persons in India requiring curative treatment without hospitalization choose private providers. People go to the nearest trusted health care providers who is usually a private for-profit providers. The poor and even in hilly areas choose them. Private practitioners are perceived more sympathetic, more conveniently located, more effective and more trusted for privacy than government run services as having condescending doctors, substandard drugs, inconvenient opening hours and long waiting times. However, once patients had switched from private to government run providers, they become far more appreciative of government-run services, drugs and staff. TB patient’s health seeking behaviour is dependent of their symptoms. About half of the TB patients seek help within a month, 50 to 80% from private for-profit providers. Diagnosis of TB is often delayed for weeks after first contact with a private provider. Almost 75% of smear positive patients found in the care of private doctors in mid-seventies were not being treated for TB. About half the patients continue treatment with the private providers who diagnosed the TB.

Most patients knew that they have TB even when the providers try to conceal this stigmatizing diagnosis. They knew that TB requires prolonged regular treatment. They start taking drugs, but loose interest after relief specially the low-income groups due to cost and inconvenience of taking drugs. With the passage of time, work and social commitments increasingly displace the chore of taking regular treatment. Even knowledge about consequence of irregular treatment did not prevent it. As their funds get depleted TB patients switch to government run services. The steady switching from private to government run services is not matched by switching from government-run to private providers. Except where DOTS is practiced, do not achieve consistent cure. With DOTS, 80% cure rate was demonstrated in pilot area while only 35% with standard regimen and 51.3% on SCC completed treatment in NTP. As implied by these events, long-duration patients accumulate in government-run services. Many TB patients believe that TB carries a social stigma. Ex-TB patients are less likely than average to find marriage partners in West Bengal. Unmarried girls with TB fear that they might never find a spouse, those married fears divorce. Women are typically less well placed than men to ensure their own cure.

Out of pocket costs for diagnosis and successful treatment in India are estimated at between 100 and 150 US Dollars per patient as per 1992-1995 rupees dollar rates. However, individual out of pocket expenditure on TB treatment dwarfs the substantial sums expended by the government on the NTCP. However, private expenditures on private TB treatment, which are estimated to exceed USD 150 million per year, are typically rewarded by palliation rather than cure of TB.

Over-diagnosis and over-prescription among private for-profit providers are predictable. X-ray was found the test of choice to rule out TB, with sputum examination done in only 10 to 20% of suspects. Treatment regimens prescribed were of 4 drugs intensive phase with six months duration and were probably adequate to achieve cure. Most of them prescribed anti-TB drugs and also gave expensive diet supplements and alcohol based tonics.

Private practitioners generally keep no patient records. Half of them admitted that they made no attempt to contact patients who defaulted from follow up visits. Only 5% stated that sputum negative smears were desired to call it a cured case. TB patients do not form an important part of the business; only 1% of patients seeking care at qualified allopathic provider while one-third had no patients. TB Specialists might consider TB as an importantpart of their business. Government services are normally free, but waiting time, wages lost and drug unavailability impose costs and inconveniences. Spot checks revealed that more than 50% of PHCs had one or more TB drugs not available. Only 15% of the patients knew that the treatment is free in government clinics. On the whole, government-run health care services in India have a poor image. The private for-profit health care sector plays a major health care / system in India. In 1989, there were about 2,42,650 qualified allopathic physicians as compared to 88,105 in the government services. The number of recognised hospitals in private sector grew from 2,764 in 1983 to 4488 in 1987. The profile of a typical rural private provider in Uttar Pradesh was a 38 year old male, with about 10-12 years of schooling, practicing a mixture of western and professional medicines. Only 7% were qualified, while 90% learn the skills from family members, or as compounders, pharmacist or as doctor’s assistants. Nearly all the rural practitioners sell medicines by margin added to the medications. About half of them were registered with some medical association.

Drug retailers in India consistently sell restricted drugs without requiring prescription. The legal and regulatory environment for health care in India is in a state of flux. On paper fairly well regulated but unregulated in practice. Consumer Protection Council (CPC) in India has taken an active role in pursuing cases of malpractice. However, CPC’s role has been questioned by the IMA and Supreme Court ruling.

Some important gaps in information persist. There is no reliable estimate of the number, density and distribution of specialist clinics where TB might form a more important part of the case load. Several options for interventions have been identified. Excluding TB drugs from private channels such as in Algeria and Chile. Mandatory referral of TB patients to government-run services such as in Oman. To run high quality and low costs to patients.

Involvement of private providers in the programme by modifying the prescribing behaviour by academic counseling. In any case complete regular treatment and standardized monitoring promise a greater improvement than changes in prescribing alone.

Non-adherence to treatment is an obstacle to the control of TB. Among many reasons mentioned for non-adherence, providers’ attitude, behaviour and knowledge and skill in dealing with TB patients has been cited as an important factor. Few studies also indicate that communication between patient and provider during interaction also plays an important role in the therapeutic process. Hence, this present study on patient-provider interaction was designed to describe some of the factors affecting adherence to TB treatment at LWTDTC, at urban district of Bangalore and its catchment area. The main objectives of the study were to find out the rate of adherence, application of present national control programme, patient perception of DOTS, retrospective elucidation of patient provider interaction and its influence on adherence to treatment. Treatment cards of a total of 602 smear positive patients treated with SCC regimen during Jan to Sept 1997 were analysed. From among them, 11 completed patients and 13 non-adherent patients were selected by systematic random sampling for subsequent interviewing. Further, 10 patients out of 153 patients who were under treatment from April to May 1998 and 15 patients receiving DOTS from 4 Treatment Units were selected by purposive sampling for the interviews. In addition, 23 health care providers (physicians, nurses, health visitors, laboratory technicians and health workers) were interviewed.

Most of the patients interviewed have sought the help of private health services prior to their diagnosis with the belief that their illness is not severe and attributed to cold, fever and viral infections. A majority of the patients were diagnosed within four weeks at the place of treatment. Only some had delay of more than 4 weeks. They were either referred by the initial provider (majority) or by self-motivation. Of the 602 patients, 449 (74.5%) did not complete the treatment. The non-adherence was more significant in the age group of 21-40 years. Defaulting was higher among males than females. The defaulting was early, as 64.3% defaulted within three months. None of the non-adherent patients reported having received a letter or being personally contacted by the staff. The patients put on DOTS had a separate box of anti-TB drugs for him/her and were given drugs in the intensive phase three times a week under direct observation and once a week in the continuation phase and two doses for self-administration. The results were that 74.2% of the patients put on DOTS were cured at the end of treatment. The providers have strong belief that DOTS is the answer to the problem of low adherence.

The most common reasons given for non-adherence by patients, providers and key informants, were lack of family support, providers behaviour, drug side effect, disappearance of symptoms, alcohol and smoking. Adherent patients attributed family support, self-motivation and providers’ assurance as motivating factors for completion of the treatment.