Last updated:
Over the past ten years, notifications from the region have seen a 24.5-fold increase – from 38,569 in 2013 to an all-time high of 9,50,307 in 2024.
Between 2020 and 2025, Bihar notified 8,96,398 TB patients, of which 5,22,898 – about 58 per cent – were identified through the private sector. (AI generated image)
For years, tuberculosis numbers in Bihar appeared to be lower than the reality on the ground. The main reason for this was that many patients never appeared in government records – they went straight to private doctors for treatment. Long before this was confirmed by national survey data, state health officials had already realized that a large number of TB patients were seeking care in the private sector and were therefore falling out of the government’s tracking system.
That understanding shaped Bihar’s response as the COVID-19 pandemic disrupted routine health services and exposed the dangers of undetected and untreated TB. In early 2020, the state began restructuring its tuberculosis strategy by formally involving the private sector through a network of Private Provider Support Agencies, or PPSAs, to ensure that patients seeking care outside the public system are identified, informed, and brought under standardized treatment.
The scale of this challenge was later determined by the National TB Prevalence Survey (2019-21) conducted by the Indian Council of Medical Research. The survey found that while nationally about half of TB patients seek care in the private sector, in Bihar the proportion is much higher at 67 per cent, strengthening the justification for the state’s early course correction. In the last 5 years (from 2020 to 2025), 5,52,837 TB cases out of a total of 10,01,340 cases have been notified, of which 59 per cent are from the private sector.
Over the past ten years, private sector notifications have seen a 24.5-fold increase – from 38,569 in 2013 to an all-time high of 9,50,307 in 2024.
“India’s private healthcare landscape is highly fragmented, comprising practitioners of modern and traditional medicine, pharmacists, clinical laboratories and informal providers, especially in rural and tribal areas,” Dr Bal Krishna Mishra, Bihar’s state program officer (tuberculosis), told News18.
“Many of these providers do not consistently adhere to standards of TB care in India, raising concerns about delayed diagnosis, inconsistent treatment and weak follow-up in the national TB elimination programme.”
He said that personal care is also expensive for patients. “The TB prevalence survey estimated the average out-of-pocket expense for diagnosis and treatment to be Rs 6,000, with out-of-pocket expenses ranging from Rs 1,000 to Rs 28,000.”
How were private players included?
In March 2020, Bihar signed MoUs with two non-profit organizations to act as Patient Provider Support Agencies (PPSAs) in 14 districts. NGO World Health Partners was assigned districts including Patna, Bhojpur, Nalanda, Gaya, Bhagalpur, Munger, Katihar and Saharsa, while NGO Doctors for You covered West Champaran, Siwan, Gopalganj, Samastipur, Vaishali and Begusarai. Selected through technical and financial bidding, these agencies were tasked with integrating private healthcare providers into the TB control framework of the government.
The PPSA model, designed by the National TB Elimination Program as an output-based contract between state TB offices and implementing agencies, extends far beyond case notification, the official said.
These private players were asked to inform TB patients on the Nikshay portal, ensure HIV testing and antiretroviral treatment for co-infected patients, facilitate free drug-resistance testing through CB-NAAT or GeneXpert, and enroll patients under the Nikshay Nutrition Scheme, which provides Rs 1,000 per month as nutrition assistance. Treatment compliance was emphasized, with mandatory follow-up calls and physical visits when patients showed signs of treatment abandonment.
Payments to implementing agencies were linked to measurable outcomes, thereby focusing on quality of care rather than simply detection. Case notification covers 25 per cent payment, HIV testing and antiretroviral linkage for 10 per cent, drug-resistance sampling for another 25 per cent and treatment compliance for 40 per cent, bringing the total per patient payment to Rs 2,495 per successfully treated TB case.
“Although the MoU was signed in March 2020, implementation in the field began in June following Covid-related disruptions. Nevertheless, the scale-up happened rapidly. By the end of the first phase, the program had expanded to 19 districts – almost half the state – including Muzaffarpur, Darbhanga, Madhubani, Sitamarhi and East Champaran.”
Additional NGOs were involved in 2023, expanding coverage to districts such as Patna, Nalanda, Arwal and Saharsa, and by 2025, the PPSA model was implemented in all 38 districts of Bihar.
In 2016-17, notifications from the public sector were around 3,000, according to Dr Neeta Jha, former director of sustainable interventions at World Health Partners (WHP), one of the NGOs working with the Bihar government. “More than 70 per cent of patients were seeking care in the private sector. We spoke to chemists and found that prescriptions for TB drugs were largely being issued by private practitioners.”
This clearly indicates that the true burden of TB is unknown, he said, as many private doctors were not reporting cases.
Speaking about his ground experience, he said, “TB drugs were prescribed by a general practitioner other than a pulmonologist. Extrapulmonary TB cases were also 25-30 per cent, which were prescribed by orthologists, gynecologists and gastroenterologists.”
“We also noticed that TB drugs were being prescribed not only by pulmonologists but also by gynecologists and other specialists. It became clear that the system needed reform.”
He said that by the second year of privatization, notifications from the private sector had increased to 17,000 compared to about 4,000 notifications from the public sector. This meant that the private sector was reporting almost four times more TB cases than the public system.
ground effect
The data shows that the impact has been substantial. Between 2020 and 2025, Bihar notified 8,96,398 TB patients, of which 5,22,898 – about 58 per cent – were identified through the private sector. Since 2021, private sector notifications in the state have consistently outnumbered public facilities, underscoring how effectively patients have been brought back under government surveillance.
To further expand the reach, the state introduced ultra-portable, AI-enabled handheld X-ray machines that are capable of examining patients at homes, railway stations and public gatherings. Using fixed digital X-ray facilities, 8,13,650 X-rays have been conducted, identifying 42,319 probable TB cases. The handheld devices have screened 2,61,572 individuals and detected 31,248 presumptive cases, all of whom were sent for confirmatory molecular testing.
As well as private sector participation, Bihar invested heavily in diagnostic capacity using state resources. The government installed 91 CB-NAAT machines and 560 TrueNAT machines, enabling more than 35 lakh TB tests to be conducted annually. It also deployed 495 digital X-ray machines in health facilities, most of which were located in the private sector but operated by NGOs with their own radiologists, ensuring screening at zero or negligible cost to patients.
“With no effective adult TB vaccine currently available, Bihar is relying on early detection and uninterrupted treatment as its primary defence,” Mishra said. Orders have already been placed for 527 additional handheld X-ray machines, with deliveries underway, indicating that moving diagnostics closer to where patients actually seek care – particularly in the private sector – is now central to the state’s TB elimination strategy.
P.P.S.A all over India
The PPSA model is currently operational in over 200 high burden districts across India; However, Bihar has been considered as one of the most successful case studies.
A senior official of the Ministry of Health and Family Welfare said, “The strongest PPSA implementation outside Bihar has been in Uttar Pradesh, where cities like Lucknow, Kanpur, Varanasi and districts of western UP have adopted private sector participation. Maharashtra, especially Mumbai, Thane and Pune, are also using the same model.”
“Tamil Nadu, Karnataka, especially Telangana and Andhra Pradesh, where large corporate hospitals and diagnostics chains were brought into routine TB notification and West Bengal, especially Kolkata and surrounding districts, are also using the PPSA model to capture private patients. With time, the model is being expanded across India, hopefully the results will be similar to what we have seen in Bihar.”
January 29, 2026, 14:34 IST
read more
