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Unannounced assessments reveal variation, deficits, in quality of tuberculosis care in urban India



IMAGE: Private sector health care providers, the first point of contact for 50-70 percent of patients with tuberculosis (TB) symptoms in India, are delivering a wide range of largely inadequate care... view more 

Credit: CDC, Amanda Mills

Private sector health care providers, the first point of contact for 50-70% of patients with tuberculosis (TB) symptoms in India, are delivering a wide range of largely inadequate care to these patients according to a study published this week in PLOS Medicine. Researchers Ada Kwan, Ben Daniels, Jishnu Das (World Bank, Washington DC, United States), Madhukar Pai (McGill University, Montreal, Canada) and colleagues utilized 24 standardized patients (SPs) - actors trained to portray 4 different tuberculosis case scenarios during unannounced visits -- to assess management and quality outcomes of private care for TB in the Indian cities of Patna and Mumbai.

The researchers analyzed 2,602 SP-provider interactions across 473 Patna providers and 730 Mumbai providers and found that providers managed SP cases according to national and international standards in only 949 interactions (35% after weighting for city-representative interpretation; 95% CI 32%-37%). Allopathic providers with Bachelor of Medicine, Bachelor of Surgery (MBBS) degrees or higher were more likely to correctly manage cases than non-MBBS providers (odds ratio 2.80; 95% CI 2.05-3.82; p < 0.0001). However, within each qualification stratum, there was a wide range of observed quality and multiple treatment protocols. The researchers also found that providers stick to their often erroneous protocols, repeating their own observed actions 75% of the time. Providers were also more likely to manage a case correctly when they were presented with more diagnostic information.

The authors note that SPs cannot account for the broader mix of patients a provider sees or assess how a provider might manage a patient in subsequent visits. Neither are there data from the public sector to which this care can be compared. Nevertheless, these results indicate that improving TB management among urban India's private health sector should be a priority for India's TB elimination strategy.


Peer-reviewed / Experimental Study / People

Research Article


This study was funded by Grand Challenges Canada (S5 0373-01), the Bill & Melinda Gates Foundation (OPP1091843), and the Knowledge for Change Program at the World Bank. SS is supported by the Center for Operational Research, The Union (Paris, France). RS is supported by a grant from the Bill & Melinda Gates Foundation via the Arcady group (OPP1154665) and a Doris Duke Clinical Scientist Development Award, and acknowledges prior support from a Harvard Center for AIDS Research (5P30AI060354-13) and a Harvard Catalyst KL2/CMERIT Award (KL2 TR001100). MP is a recipient of a Tier 1 Canada Research Chair from Canadian Institutes of Health Research. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

Competing Interests:

I have read the journal's policy, and the authors of this manuscript have the following competing interests: MP is a member of the Editorial Boards of PLOS Medicine and PLOS ONE and is also an editor of the PLOS Tuberculosis Channel. MP previously served as a consultant to the Bill & Melinda Gates Foundation. The other authors have no competing interests to declare.


Kwan A, Daniels B, Saria V, Satyanarayana S, Subbaraman R, McDowell A, et al. (2018) Variations in the quality of tuberculosis care in urban India: A cross-sectional, standardized patient study in two cities. PLoS Med 15(9): e1002653.

Image Credit: CDC, Amanda Mills

Author Affiliations:

Development Research Group, The World Bank, Washington, District of Columbia, United States of America

University of California at Berkeley, Berkeley, California, United States of America

Institute for Socio-Economic Research on Development and Democracy, Delhi, India

Center for Operational Research, International Union Against TB and Lung Diseases, Paris, France

Department of Public Health and Community Medicine, Tufts University School of Medicine, Boston, Massachusetts, United States of America

Centre National de la Recherche Scientifique, Paris, France

ACCESS Health International, New York, New York, United States of America

Department of Anthropology, Johns Hopkins University, Baltimore, Maryland, United States of America

Center for Policy Research, New Delhi, India

McGill International TB Centre, McGill University, Montreal, Canada

Manipal McGill Centre for Infectious Diseases, Manipal Academy of Higher Education, Manipal, India

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