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 1“Shri J P Naddda launches new initiatives to combat TB”, 2017,
Elimination as defined by the World Health Organisation (WHO), means that there should be less than 1 case of 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. The National Strategic Plan 2017 - 2025, sets out the government plans of how the elimination of TB can be achieved.
Some parts of the media are now questioning whether elimination of TB by 2025 is realistically achievable.
Given the disease burden of tuberculosis in the country and the lack of funding from the centre, the Prime Minister's promise looks a little less than achievable.2PM's Promise to Eradicate TB by 2025 Far-fetched?, 2019, https://www.newsclick.in/Tuberculosis-Ayush-WHO-Modi-Government-Eradicate-TB-2025
TB Burden in India
India accounts for about a quarter of the global TB burden. Worldwide India is the country with the highest burden of both TB and MDR TB. 3“Global TB Report 2017”, WHO, 2017 There are an estimated 79,000 multi-drug resistant TB patients among the notified cases of pulmonary TB each year. India is also the country with the second highest number (after South Africa) of estimated HIV associated TB cases. For more see TB & HIV in South Africa.
In 2016 an estimated 28 lakh cases occurred and 4.5 lakh people died due to TB. 4“Global TB Report 2017”, WHO, 2017
India also has more than a million “missing” cases every year that are not notified and most remain either undiagnosed or unaccountably and inadequately diagnosed and treated in the private sector. There are some more TB statistics for India.
In 2016, and as a result of new information being available, the GoI together with the World Health Organisation revised upwards the estimates for the burden of TB in India.
Private & Public Care
TB treatment & care in India is provided in the public sector by the government’s Revised National TB Control Programme (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 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.”
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.5Denny, J, Treatment is free, yet 1 in 4 Indian TB patients must sell assets or borrow money, June 1 2019, IndiaSpend
National Strategic Plan (NSP) 2012 -2017
The RNTCP is responsible for implementing the GoI’s five year plans to combat TB.
For the five year National Strategic Plan for 2012 - 2017, the vision of the government was for a TB free India through achieving Universal Access. This was to be through the provision of quality diagnosis and treatment for all TB patients in the community. This was a major policy change.
The policy change meant extending the reach of RNTCP services to all people diagnosed with TB, including those with drug resistant TB, as well as those seeking treatment in the private sector.The new policy also included improving the quality of existing RNTCP services.
The aim was to achieve the following targets by the end of 2015:
- early detection and treatment of at least 90% of estimated TB cases in the community, including HIV associated TB
- initial screening of all previously treated (retreatment) smear-positive TB patients for drug resistant TB and the provision of treatment services for multi drug resistant TB
- the offer of HIV counseling and testing for all TB patients, and linking HIV infected TB patients to HIV care and support
- successful treatment of at least 90% of all new TB patients, and at least 85% of all previously treated TB patients
- the extension of RNTCP services to patients diagnosed and treated in the private sector.
The Implementation of the NSP 2012 - 2017
The Joint TB Monitoring mission (JMM) of the RNTCP had brought together a number of national and international experts and organisations in 2014. They were to generally review the progress, challenges, plans and efforts of the RNTCP to control TB. The implementation of the NSP 2012 - 2017 was one of the areas looked at.
The JMM acknowledged India’s remarkable achievements in TB control over the previous ten years. This included testing more than 80 million people, detecting and treating 15 million TB patients, and saving millions of lives as a result of the efforts of the RNTCP. However, they also said that overall, and despite the improvements that had been made:
There continued to be concern about the standard of care provided in the private sector. Delays in diagnosis, the use of multiple non standard regimens for inappropriate lengths of time, the lack of a way to ensure the full course of treatment was being taken, and the recording of treatment outcomes were just some of the issues.
Standards for TB Care in India
So the Standards for TB Care in India was produced in 2014 to help ensure a successful standard of diagnosis and treatment. The Standards for TB Care in India, set out the standard of TB treatment in India and TB testing & diagnosis in India that should be provided by the RNTCP in all parts of India.6“ Standards for TB care in India
www.searo.who.int/india/publications/en/ This was subsequently endorsed by the Ministry of Health and Family Welfare. Among other points this acknowledged that patients would need to be treated by private providers, rather than simply demanding that unwilling patients should be referred to the public sector.
In 2016 the RNTCP published revised technical and operational guidance. The new guidelines, the RNTCP Technical and Operational Guidelines for Tuberculosis Control in India 2016, did not replace the previous guidance (the Standards of TB Care in India), but they provide updated recommendations. They also make it absolutely clear that the guidance applies to the private sector as well as the public sector.
National Strategic Plan (NSP) 2017 - 2025
One of the main changes in this strategic plan, is that the emphasis is going to be on reaching patients seeking care from private providers. So this NSP builds on the work already done with the new RNTCP operating guidelines. The RNTCP will also be helping private providers to provide quality care and treatment, rather than encouraging the private providers to send their patients to get care from the RNTCP. The cost of implementing the new NSP is estimated at US$ 2.5 billion over the first three years. This is a large increase over the budget for the current NSP.
The NSP plans to provide incentives to private providers for following the standard protocols for diagnosis and treatment as well as for notifying the government of cases.7“India’s ambitious new plan to conquer TB needs cash and commitment”, The Conversation, October 4, 2017 https://theconversation.com/indias-ambitious-new-plan-to-conquer-tb-needs-cash-and-commitment-84821 Also patients referred to the government will receive a cash transfer to compensate them for the direct and indirect costs of undergoing treatment and as an incentive to complete treatment. This has already been trialed in some pilot projects.
"When I visited the largest slum in Mumbai with over one million people, I saw a model of care that seems to work whereby private practioners are empowered to detect and report TB cases through the support of an NGO and patients are mobilized to access TB services through the incentive of vouchers"
Dr Mario Raviglione, Director WHO Global TB Programme 8“India on the right path to ending TB”, World Health Organization, 2016,www.searo.who.int/india/mediacentre/events/2016/
Integrating TB Control in the Private and Public Sectors
However, some people, such as AIDS-Free World Co-Director Stephen Lewis, think that it will be almost impossible to integrate TB control in the private and public sectors. Apart from good intentions, and the occasional intervention, he believes that there is very little to give confidence that the gap will be bridged. There are some limited initiatives, such as the Public Private Interface Model. But when visiting a public sector nursing home implementing this initiative, a private sector doctor told him that there were:
"too many patients, no drugs, costs (including transportation and doctor’s fees) impossible for patients to afford, poor follow up, minimal counselling, endless waits, family disruption, rampant stigma, extreme illness, ignorance among the clinicians .. a litany of vociferous despair"9 “Statement by AIDS-Free World Co-Director Stephen Lewis upon returning from an October (2017) fact-finding trip to Mumbai and Delhi to assess tuberculosis in India”, https://www.newslaundry.com/2017/10/30/tb-control-india-eradication-tuberculosis-stephen-lewis
So has India turned a corner?
Some people believe that India has dramatically turned the corner on TB.
The government is calling for the elimination of TB by 2025, and there is a new National Strategic Plan 2017 - 2025 with ambitious ideas endorsed by the government. The financial resources for TB control for 2017 - 2025 are to be doubled, the diagnostic tool CB-NAAT is to be rolled out across the country and the two new drugs bedaquiline and delamanid are also scheduled for broader rollout. First and second line drug susceptibility testing is in use or at least on the agenda. Also, patients with TB are tested for HIV and patients with HIV are tested for TB. Drug treatment is moving from intermittent therapy to daily fixed dose combinations. The private sector is to be engaged and the Prime Minister has added his voice to the crescendo of endorsement.
But can all this be achieved? Where is the sense of urgency as the first year of the NSP is completed? Only time will tell as progress is monitored through a series of impact indicators.
Impact Indicators for the National Strategic Plan 2017 - 2025
|To reduce estimated TB incidence (rate per 100,000)||217||142||77||77|
|To reduce estimated TB prevalence (rate per 100,000)||320||170||90||65|
|To reduce estimated mortality due to TB (per 100,000)||32||15||6||3|
|To achieve zero catastrophic costs for affected families due to TB||35%||0%||0%||0%|
If there is a "plus sign" click on it for more columns.
There are also a number of TB outcome indicators giving the 2025 figures and targets for indicators such as:
- The number of patients notified from the public sector;
- The number of patients notified from the private sector;“
- The number of patients with drug resistant TB;
- The number of patients initiated on treatment;
- and the treatment success rate.