Disease burden outpaces essential diagnostic test availability for Neglected Tropical Diseases in India

A cross-sectional assessment of 332 public health facilities in India reveals a critical mismatch where diagnostic availability for most Neglected Tropical Diseases remains low and poorly aligned with local disease burden, particularly at peripheral primary care levels, despite high programmatic prioritization for malaria.

The Gist

Imagine India's public health system as a massive, multi-story hospital building with four distinct floors, each designed to catch different levels of illness:

1. The Ground Floor (Sub-Centers): The neighborhood clinics where you first walk in.
2. The First Floor (Primary Health Centers): Slightly bigger clinics with a bit more equipment.
3. The Second Floor (Community Health Centers): Larger hubs with specialized doctors.
4. The Penthouse (District Hospitals): The big, fully equipped hospitals at the top.

This study is like a building inspector walking through 332 of these "floors" across seven different states to check if they have the right tools (diagnostic tests) to catch specific diseases. The diseases in question are the "Neglected Tropical Diseases" (NTDs)—illnesses like Dengue, Malaria, Filariasis (which causes swelling in legs), and others that thrive in poverty but are often ignored.

Here is the simple breakdown of what the inspectors found:

1. The "Star Student": Malaria

If the health system were a classroom, Malaria would be the student who always gets an A+.

• The Situation: Because the government has focused heavily on Malaria for decades, almost every single floor of the building has the right tools to test for it. Even the tiny Ground Floor clinics have rapid test kits.
• The Result: If you have Malaria, you can likely get tested right where you live.

2. The "Struggling Students": Dengue, Filariasis, and Leishmaniasis

Now, look at the other diseases. They are like students who are failing the test because the school forgot to give them the right textbooks.

• The Problem: Even though these diseases are very common and dangerous, the tools to test for them are missing.
• The Analogy: Imagine you have a broken leg (a serious disease), but the clinic on the Ground Floor doesn't have an X-ray machine. They tell you, "Go to the Penthouse (District Hospital) at the top of the building to get an X-ray."
• The Reality: For diseases like Filariasis (swelling), Leishmaniasis (a deadly parasite), and Japanese Encephalitis, the "X-ray machines" are almost non-existent on the Ground and First Floors.
  • Filariasis: Only about 5% of Ground Floor clinics could test for it.
  • Leishmaniasis: Only about 6% of clinics had the test.
  • Japanese Encephalitis: A mere 8% had the test.

3. The "Upstairs vs. Downstairs" Gap

The study found a huge gap between the top and bottom of the building.

• The Penthouse (District Hospitals): These are well-stocked. They have almost all the tools.
• The Ground Floor (Sub-Centers): This is where the poor and vulnerable people live. They are the first to get sick, but they are the last to get tested.
• The Metaphor: It's like having a fire alarm system that only works on the 10th floor. If a fire starts on the 1st floor (where most people live), no one hears the alarm until it's too late.

4. The "Mismatch" Problem

The most frustrating part of the study is the mismatch.

• In some districts, thousands of people are getting sick with Dengue or Filariasis (high "disease burden").
• Yet, in those exact same districts, the local clinics have zero tests for those diseases.
• The Analogy: It's like a town that is constantly getting flooded with rain (disease), but the town council refuses to buy any umbrellas or raincoats (tests) for the people living there. They only have umbrellas in the fancy hotel downtown, far away from the flood.

5. Why Does This Matter?

When you can't test for a disease early:

• People suffer longer: They get sicker before they get help.
• Outbreaks spread: Doctors don't know a disease is spreading until it's too late to stop it.
• Trust is lost: People stop going to government clinics because they know the tests aren't there, and they turn to expensive private doctors or unqualified healers.

The Bottom Line

The paper concludes that India is doing a great job with Malaria, but it is neglecting the other neglected diseases.

To fix this, the authors suggest we need to stop hoarding the "tools" at the top of the building. We need to bring the "X-ray machines" down to the Ground Floor. We need to put the diagnostic kits in the hands of the local health workers who see the sick people first. Only then can we catch these diseases early, stop them from spreading, and actually eliminate them.

In short: We have the tools to fight these diseases, but they are sitting on the wrong shelves. We need to move them to where the sick people actually are.

Technical Summary

1. Problem Statement

India carries a significant burden of Neglected Tropical Diseases (NTDs), including vector-borne viral infections (Dengue, Chikungunya, Japanese Encephalitis), parasitic diseases (Malaria, Lymphatic Filariasis, Leishmaniasis, Helminthic infections), and HIV. Despite the existence of the ICMR National Essential Diagnostics List (NEDL) 2019, which outlines recommended diagnostic tests for various levels of public health facilities, there is a critical lack of data regarding the actual availability of these tests on the ground.

The core problem identified is a mismatch between disease burden and diagnostic readiness. While "Big Three" diseases like Malaria and HIV have seen sustained programmatic prioritization, other NTDs often lack essential diagnostic infrastructure at the primary and peripheral levels (Sub-Centers and Primary Health Centers). This gap leads to delayed case detection, inaccurate surveillance, ineffective outbreak response, and continued transmission, particularly in vulnerable, resource-limited populations.

2. Methodology

• Study Design: A cross-sectional descriptive survey conducted between November 2023 and April 2025.
• Setting: The study covered 332 public health facilities across 24 districts in seven states and one Union Territory (Assam, Delhi, Haryana, Himachal Pradesh, Manipur, Rajasthan, Tripura, and Uttar Pradesh).
• Facility Tiers: The survey included the full spectrum of India's public health system:
  • Sub-Centers (SCs): $n=76$
  • Primary Health Centers (PHCs): $n=152$
  • Community Health Centers (CHCs): $n=80$
  • District Hospitals (DHs): $n=24$
• Data Collection: Trained teams used a standardized checklist based on the ICMR NEDL 2019 to verify the physical availability and functionality of specific diagnostic tests on the day of the visit.
• Key Metric: The Diagnostic Readiness Index (DRI) was calculated for each facility, district, and state.
  • Formula: $DRI = (\text{Number of NEDL Recommended Tests Available} / \text{Total NEDL Tests Required}) \times 100$.
• Statistical Analysis: Descriptive statistics were used for facility characteristics. The Kruskal–Wallis test and One-Way ANOVA were employed to compare DRI across facility tiers. National burden data (2021–2025) was sourced from NCVBDC, WHO, and published reports for correlation analysis.

3. Key Contributions

• First Large-Scale Multi-State Assessment: This study provides the most comprehensive mapping of NTD diagnostic availability across multiple tiers of the Indian public health system, moving beyond single-disease or single-state studies.
• Quantification of the "Diagnostic Gap": It introduces and applies the Diagnostic Readiness Index (DRI) to quantify the disparity between policy recommendations (NEDL) and actual implementation.
• Burden vs. Capacity Correlation: The study explicitly correlates local disease burden with diagnostic availability, revealing that high-burden areas do not necessarily possess high diagnostic capacity.
• Policy Evidence: It offers granular, state-level data to guide the National Health Mission (NHM) and state health departments in resource allocation and supply chain strengthening.

4. Key Results

The study found a tiered gradient in diagnostic readiness, where availability increases with the level of care, but remains critically low for most NTDs at the primary level.

• Overall Readiness:

  • District Hospitals (DHs): Highest mean DRI (67.19%).
  • Community Health Centers (CHCs): Moderate mean DRI (48.93%).
  • Sub-Centers (SCs): Low mean DRI (42.11%).
  • Primary Health Centers (PHCs): Lowest mean DRI (32.42%).

• Disease-Specific Findings:

  • Malaria: The only disease with high readiness across all tiers (Mean District DRI: 84.34%). SCs showed 81.58% readiness, reflecting successful programmatic decentralization.
  • HIV: Generally high readiness at PHCs, CHCs, and DHs (Mean District DRI: 57.23%), but lower at SCs.
  • Dengue: Moderate overall readiness (40.36%), but highly variable. Readiness drops significantly at PHCs (37.50%) and SCs (where it is often "Not Recommended" per NEDL, leading to 0% availability).
  • Lymphatic Filariasis: Critically low readiness (29.22%). SCs had only 5.26% readiness, indicating a massive gap in peripheral surveillance.
  • Helminthic Infections: Very low readiness (25.30%), with SCs showing 0% availability.
  • Japanese Encephalitis (JE): Extremely poor readiness (8.13%), with SCs and PHCs largely devoid of testing capabilities.
  • Leishmaniasis (Kala-azar): The lowest readiness (5.72%), despite the availability of simple rK39 RDTs.

• State-Level Variations:

  • Delhi and Manipur showed relatively higher overall diagnostic coverage.
  • Himachal Pradesh and Rajasthan had high Malaria readiness but near-zero readiness for Dengue and JE at the PHC level.
  • Tripura showed high readiness for Filariasis and Dengue but gaps in other areas.

• The Mismatch: The study highlights that districts with substantial reported disease burdens (e.g., for JE, Filariasis, and Leishmaniasis) often have the lowest diagnostic readiness, particularly at the Sub-Center and PHC levels where patients first seek care.

5. Significance and Implications

• Systemic Failure in Decentralization: The findings indicate that while the NEDL exists, its implementation is failing at the "last mile." Essential diagnostics are concentrated in District Hospitals, forcing patients from rural areas to travel long distances for confirmation, leading to delayed treatment and increased mortality/morbidity.
• Surveillance Blind Spots: The lack of peripheral diagnostics for diseases like JE and Leishmaniasis means outbreaks may go undetected until they are widespread, undermining the WHO 2030 NTD elimination roadmap.
• Strategic Recommendations:
  • Decentralization: Urgent need to deploy Point-of-Care (POC) diagnostics (e.g., rK39 for Leishmaniasis, NS1/IgM for Dengue) to SCs and PHCs.
  • Supply Chain Strengthening: Addressing procurement and logistics bottlenecks that prevent tests from reaching peripheral facilities.
  • Workforce Training: Enhancing the capacity of frontline health workers to perform and interpret basic diagnostic tests.
  • Burden-Informed Planning: Resource allocation must be driven by local epidemiological data rather than historical funding patterns.

Conclusion: The paper concludes that India's NTD control efforts are being undermined by a "diagnostic desert" at the primary care level. Aligning diagnostic deployment with the actual disease burden is critical to achieving national control targets and ensuring equitable healthcare access.