TB in India - Elimination, NSPs & COVID

The Elimination of TB in India

In March 2017 the Government of India (GoI) announced that the new aim with regard to TB in India was the elimination of TB by 2025.

"Ensuring affordable and quality healthcare to the population is a priority for the government and we are committed to achieving zero TB deaths and therefore we need to re-strategize, think afresh and have to be aggressive in our approach to end TB by 2025"

Shri J P Nadda, Union Minister of Health and Family Welfare

Elimination as defined by the World Health Organisation (WHO), means that there should be less than 1 person with TB for a population of a million people.

In view of the current TB burden in India, there is a great deal that needs to be done if elimination is to be achieved by 2025.

Burden of TB in India

India accounts for about a quarter of the global TB burden. In 2019 the estimated TB incidence was 2,640,000.

In 2019 an estimated 9,500 HIV positive people died due to TB disease , and an estimated 436,000 HIV negative people died. 1“Global TB Report 2020”, WHO, 2020, https://www.who.int/tb/publications/global_report/en/. There are some more TB statistics for India.

India is also the country with the second highest number (after South Africa) of estimated HIV associated TB cases.

Drug Resistant TB

Worldwide India is the country with the highest burden of both TB and MDR TB. 2“Global TB Report 2020”, WHO, 2020, https://www.who.int/tb/publications/global_report/en/ The estimated incidence of people with MDR/RR-TB is 130,000.

There is more about drug resistant TB in India, including the treatment of drug resistant TB. The level of drug resistant TB is one of a number of factors that could result in India missing its target of eliminating TB by 2025.

Private & Public Care

TB treatment & care in India is provided in the public sector by the government’s National Treatment Elimination Program (previously the RNTCP) as well as through private sector health providers. The private sector is very large, and it is believed that more than half of all TB patients in India are cared for in the private sector.

There are many reasons why people in India seek care from the private sector. These include:

  • poor knowledge of TB;
  • poor knowledge of services available through the national public program;
  • the convenience of services in the private sector;
  • a desire for confidentiality;
  • a desire for personalized care.

It has been said that:

“Many people are unaware that all the medicines needed to treat TB patients are available free of cost at Indian government hospitals. Most people tend to spend huge amounts in private hospitals.”

Free TB treatment is available at all government health centres in India

Free TB treatment is available at all government health centres in India

Also, although there is no charge for TB drugs, it has been said that many patients have to sell assets or borrow money to pay for other costs.3Denny, J, Treatment is free, yet 1 in 4 Indian TB patients must sell assets or borrow money, June 1 2019, IndiaSpend

National Strategic Plan 2017 - 2025

The National Strategic Plan 2017 - 2025 (NSP) set out the government of India's (GoI) plan of how the elimination of TB could be achieved.

In this strategic plan the emphasis was going to be on reaching patients seeking care from private providers. So this NSP built on the work already done with the new NTEP operating guidelines.

The NTEP was going to be helping private providers to provide quality care and treatment. This was instead of encouraging the private providers to send their patients to get care from the NTEP.

The NSP 2017 -2025 outlined key governance interventions and structures that needed to be in place if TB was to be eliminated by 2025.

Nutritional Support for TB Patients

In 2018 the government launched the Nikshay Poshan Yojana, a direct benefit transfer scheme to provide nutritional support for TB patients. This was one of a number  of Direct Benefit Transfer schemes.

United Nations High Level Meeting on Tuberculosis

2018 also saw the first ever UN General Assembly (UNGA) high level meeting on Tuberculosis. The meeting resulted in the adoption of a Political Declaration on Tuberculosis which reaffirmed the committment to end the tuberculosis epidemic by 2030.

It included ambitious targets for the scale-up of tuberculosis care and prevention services, as well as commitments on research for new tools, principles of equity and human rights, and targets for both implementation and research.

As a signatory to the declaration, India made a committment to reach the UNHLM targets.

 20182019202020212022Cumulative
2018-2022

TB diagnosis and treatment targets2,143,2002,693,1002,519,6002,353,1002,191,00011,900,000
MDR-TB diagnosis and treatment targets36,200
39,70066,100122,300142,300406,600
Total Preventative Therapy targets378,100900,3001,489,3001,959,7002,270,0006,997,400
Childhood TB diagnosis and treatment targets130,400174,200179,400181,000179,200844,200

Launch of TB Harega Desh Jeetega Campaign

By September 2019 it was clear that in many areas more effective action was needed. Dr Harsh Vardhan, the Union Minister for Health and Family Welfare, launched the new TB Harega Desh Jeetega Campaign.

It was said that multi-stakeholder and community participation would form the core of the countrywide campaign.4"Dr Harsh Vardhan launches 'TB Harega Desh Jeetega' Campaign", 2019, Press Information Bureau, https://pib.gov.in/newsite/PrintRelease.aspx?relid=193409

The National Strategic Plan 2020 - 2025

At the same time an assessment took place of the progress that had been made with the NSP 2017 - 2025. This was helped by the Report of the Joint Monitoring Mission, carried out by the NTEP and the WHO. Key governance interventions and structures had been identified that needed to be in place to end TB by 2025. But the planned expansion and restructuring of the NTEP had not happened.

Because of this and the rapidly changing environment within which the NTEP was operating it was also decided to produce an updated NSP, the NSP 2020-25.

The NSP 2020-25 is a framework to guide the activities of all stakeholders. It is a five year strategy document that aims to direct the attention of all stakeholders to the most important interventions that the GoI believes will bring about significant changes in the incidence, prevalence and mortality of TB.

These strategies and interventions are in additon to the processes and activities already ongoing in the country.

Sub-national certification of "Disease Free" Status

To achieve the targets of the elimination of a number of communicable diseases, and of TB in particular, by 2025, certain new disease control initiatives are to be taken.

One of the most significant of these is the Sub-National Certification of Disease Free Status, a new important initiative of the NTEP. The intention is that this will provide awards for those States/Districts which achieve TB free status.

Impact of COVID-19 on TB Services

The countrywide lockdown in 2020 had an adverse impact on routine health care services including those for the management of TB. Patients were unable to access routine health services.  Also individuals with symptoms of TB were unable to reach doctors/hospitals/diagnostic centres in order to get tested. A greater impact was felt by the private sector as many smaller clinics and health facilities remained closed for much of 2020.

But by mid February 2021 India had on average just 11,000 COVID cases a day. The seven day rolling average of daily deaths was below 100.5Soutik Biswas, "Covid-19: How India failed to prevent a deadly second wave", 2021, https://www.bbc.co.uk/news/world-asia-india-56771766 But within a month India was in the grip of a devastating second wave of the virus, and some cities were facing fresh lockdowns.

By mid-April 2021 the country was averaging more than 100,000 cases a day.  The hospitals were full, there was a lack of oxygen, and increasing deaths. In May the National Institute of Tuberculosis and Respiratory Diseases (NITRD) was converted into a designated COVID Care Centre.6Delhi's NITRD designated COVID centre with 111 beds for patients, 2021, https://www.daijiworld.com/news/newsDisplay?newsID=832669

All of this must surely be having a severely detrimental effect on the provision of TB services.

So is India on course to eliminate TB by 2025?

The government is calling for the elimination of TB by 2025, and there is a new National Strategic Plan 2020 - 2025 with ambitious ideas endorsed by the government. The NSP 2020 - 2025 sets out a results framework, containing a number of indicators, through which the progress of the NSP can be monitored on a year by year basis.

Two of the indicators are the target TB patients expected to be notified in both the public and private sectors. For 2020 the figures are as follows:

Indicator2020 Target
(NSP 2017-2025)
2020 Target
(NSP 2020-2025)
Actual
(TB Report 2021)
Total TB Patients Notified 3,600,0001,500,0001,805,670
Public Sector Patients Notified1,600,0001,080,0001,249,088

Initially this looks encouraging with the Target Notifications having been achieved for 2020. However, the change from the NSP 2017 - 2025 to the NSP 2020 -2025 means that the Targets for 2020 have been lowered, and have been more easily met. This means that there is even more to be achieved in the next four years.

In a similar way another encouraging indicator is the number of MDR/RR TB Patients Notified. But again the Target Notification has been achieved for 2020, but possibly at the expense of what needs to be achieved in future years.

Indicator2020 Target
(NSP 2017-2025)
2020 Target
(NSP 2020-2025)
Actual
(TB Report 2021)
No of MDR/RR TB Patients Notified 92,00045,41949,679

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This page was last updated in May 2021.
Author Annabel Kanabus

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Major Sources for TB in India