For years, Bihar’s tuberculosis numbers looked lower than the reality on the ground. This was mainly because many patients never showed up in government records—they went straight to private doctors for
treatment. Long before national survey data confirmed it, state health officials had already realised that a large number of TB patients were seeking care in the private sector and were therefore slipping out of the government’s tracking system.
That understanding shaped Bihar’s response when the Covid-19 pandemic disrupted routine health services and exposed the risks of undetected and untreated TB. In early 2020, the state began restructuring its tuberculosis strategy by formally engaging the private sector through a network of Private Provider Support Agencies, or PPSAs, to ensure that patients seeking care outside the public system were identified, notified, and brought under standardised treatment.
The scale of this challenge was later quantified by the National TB Prevalence Survey (2019–21), conducted by the Indian Council of Medical Research. The survey found that while nearly half of TB patients nationally seek care in the private sector, in Bihar the proportion was significantly higher at 67 per cent, reinforcing the rationale for the state’s early course correction. In the last 5 years (from 2020 to 2025), 5,52,837 TB cases have been notified out of a total 10,01,340, 59 per cent of cases from the private sector.
Over the last ten years, notifications from the private sector have witnessed 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, spanning practitioners of modern and traditional medicine, pharmacists, diagnostic laboratories and informal providers, particularly in rural and tribal areas,” Dr Bal Krishna Mishra, state programme officer (tuberculosis), Bihar, told News18.
“Many of these providers do not consistently follow the standards of TB care in India, raising concerns within the National TB Elimination Programme about delayed diagnosis, inconsistent treatment and weak follow-up.”
He added that for patients, private care also comes at a high cost. “The TB prevalence survey estimated the median out-of-pocket expenditure for diagnosis and treatment at Rs 6,000, with expenses ranging from Rs 1,000 to Rs 28,000.”
How were private players onboarded?
In March 2020, Bihar signed memoranda of understanding with two non-profit organisations to function as Patient Provider Support Agencies (PPSA) across 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 Paschim Champaran, Siwan, Gopalganj, Samastipur, Vaishali and Begusarai. Selected through technical and financial bidding, these agencies were tasked with integrating private healthcare providers into the government’s TB control framework.
The PPSA model, designed by the National TB Elimination Programme as an output-based contract between state TB offices and implementing agencies, extends well beyond case notification, the officer added.
These private players were asked to notify 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 enrol patients under the Nikshay Poshan Yojana, which provides Rs 1,000 per month as nutritional support. Treatment adherence was emphasised, with mandatory follow-up calls and physical visits when patients showed signs of dropping out of therapy.
The payments to implementing agencies were linked to measurable outcomes, reinforcing the focus on quality of care rather than just detection. Case notification accounted for 25 per cent of payments, HIV testing and antiretroviral linkage for 10 per cent, drug-resistance sampling for another 25 per cent, and treatment adherence for 40 per cent, taking the total per-patient payout to Rs 2,495 per successfully treated TB case.
“Although the MoUs were signed in March 2020, field implementation began in June after Covid-related disruptions. Even so, the scale-up was rapid. By the end of the first phase, the programme had expanded to 19 districts — nearly half the state — including Muzaffarpur, Darbhanga, Madhubani, Sitamarhi and East Champaran.”
Additional NGOs were onboarded in 2023, extending coverage to districts such as Patna, Nalanda, Arwal and Saharsa, and by 2025, the PPSA model had been implemented across all 38 districts of Bihar.
According to Dr Nita Jha, former director, sustainable interventions at NGO, World Health Partners (WHP) – one of the NGOs that worked with the Bihar government – in 2016–17, notifications from the public sector hovered around 3,000. “More than 70 per cent of patients were seeking care in the private sector. We engaged with chemists and found that prescriptions for TB medicines were largely being issued by private practitioners.”
This clearly indicated that the true burden of TB was unknown, as many private doctors were not notifying cases, she said.
“TB drugs were prescribed by a general physician apart from pulmonologists. Extrapulmonary TB cases were also 25-30 per cent, which was prescribed by orthologists, gynaecologists and gastroenterologists,” she said while explaining her on-ground experience.
“We also observed that TB drugs were being prescribed not only by pulmonologists but by gynaecologists and other specialists as well. It became clear that the system needed correction.”
By the second year of privatisation, she said, private-sector notifications had risen to 17,000, compared with around 4,000 notifications from the public sector. This meant that the private sector was reporting nearly four times as many TB cases as the public system.
On-ground impact
The impact has been substantial, the data shows. Between 2020 and 2025, Bihar notified 8,96,398 TB patients, of whom 5,22,898 — nearly 58 per cent — were identified through the private sector. Since 2021, private sector notifications in the state have consistently exceeded those from public facilities, underscoring how effectively patients have been brought back under government oversight.
To further expand reach, the state introduced ultra-portable, AI-enabled handheld X-ray machines capable of screening patients in homes, railway stations and public gatherings. Using fixed digital X-ray facilities, 8,13,650 X-rays have been conducted, identifying 42,319 presumptive TB cases. Handheld devices have screened 2,61,572 individuals and detected 31,248 presumptive cases, all of whom were referred for confirmatory molecular testing.
Alongside private sector engagement, 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 across health facilities, most of them 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 for 527 additional handheld X-ray machines have already been placed, with deliveries underway, signalling that taking diagnostics closer to where patients actually seek care — particularly in the private sector — is now central to the state’s TB elimination strategy.
PPSA across India
The PPSA model is currently operational in more than 200 high-burden districts across India; however, Bihar has been considered one of the most successful case studies.
“Strongest PPSA implementations outside Bihar have been in Uttar Pradesh, where cities such as Lucknow, Kanpur, Varanasi and districts across western UP adopted private sector engagement. Maharashtra, particularly Mumbai, Thane and Pune, are also using the same model,” said a senior official from the Ministry of Health and Family Welfare.
“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. Over time, the model is being expanded across India hoping that results would be similar to what we have seen in Bihar.”
