India's private sector treats an enormous number of patients for tuberculosis (TB), appreciably more than in the public sector. Under notification of TB by the private sector remains a major issue in India, 5 years after mandatory TB notification was declared by the Government of India.
Amrita Institute of Medical Sciences (AIMS), Kerala, a private tertiary care hospital has been notifying TB patients from 2012 onwards, at an average of 15 per quarter. We looked at reasons for incomplete notification in our hospital during February 2016 by conducting key informant interviews with doctors. Identified barriers to notification were misconceptions about notification, concerns about patient confidentiality, the workload involved in the notification procedure, fear of losing patients to the government system, lack of a notification system within the hospital and lack of coordination between the public and private sectors. The motivation to notify all TB cases intensified when the Government of Kerala declared that patient confidentiality would be maintained for all those notified and that patients would not be contacted by the government system without the permission of the treating clinician. All doctors working in our hospital underwent sensitisation through training and frequent communications from the hospital administration.
To make the system more effective, a single window for TB notification, via a multipurpose worker and a Nodal Medical Officer was established. Regular reports were requested from the microbiology laboratory, which reported all sputum-positive, culture-positive and cartridge-based nucleic acid amplification testing (CB NAAT) positive cases. The medical records department shortlisted patient details with international classification of diseases coding for TB on a monthly basis. Linkage was made with the nodal department for collecting and compiling weekly Integrated Disease Surveillance Project reports, which captures details of all probable and laboratory-confirmed communicable diseases among in-patients in the hospital.
We evaluated the completeness of TB notification on a monthly basis by comparing notifications with the list obtained from the pharmacy department containing details of patients to whom anti-tuberculosis drugs had been issued. Precautions were taken to avoid duplications by generating a line list. When in doubt, patient information was checked in the hospital information system using the patient registration number. All patient details were entered into the NIKSHAY web portal for monitoring TB patients using a password issued by the district health authority. With all these initiatives, the notification figure for the hospital increased from 14 in the first quarter of 2016 to 72, 58 and 52 cases in the second, third and fourth quarters.
This process highlighted how many cases with TB are missing from the surveillance system in India. It also gave us the opportunity to quantify the number of cases diagnosed with TB in our hospital and to take the initiative to offer them the services set out in the Standards of TB Care in India.
The vision of India's national TB control programme should be that people suffering from TB need to receive the highest standards of care and support from the health care providers of their choice. The system needs to be made patient-centric by leaving the choices to the patients and promoting standards of TB care in both sectors.
Senior Medical Administrator & Public Health consultant, AIMS, Kochi, Former Additional Director of Health services& DMO, (Health) Ernakulam &SPM (RCH),NHM