TB in India - Elimination, Private Care, NSP

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,
http://medicalnewsindia.com/govt-committed-achieve-zero-tb-deaths-says-health-minister

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. 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 though questioning whether the elimination of TB in India by 2025 is realistically achievable.

Given the disease burden of tuberculosis in the country .... 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

Coranavirus & TB

There is also now the added problem of COVID-19 and TB. It is unclear what the impact of the coranavirus pandemic is going to be on the provision of TB services in India. It is also unclear what effect coronavirus will have on people with TB.

Burden of TB in India

India accounts for about a quarter of the global TB burden. In 2018 the estimated TB incidence was 2,690,000. An estimated 9,700 HIV positive people died due to TB disease , and an estimated 440,000 HIV negative people died. 3“Global TB Report 2019”, WHO, 2019, 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.

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.

Drug Resistant TB

Worldwide India is the country with the highest burden of both TB and MDR TB. 4“Global TB Report 2019”, WHO, 2019, 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 another of the factors that may cause India not to reach the target of elimination by 2025.

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 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.”

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

TB in India - Testing, diagnosis & treatment

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

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

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. 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 provided updated recommendations. They also made it absolutely clear that the guidance applied to the private sector as well as the public sector.

In 2017 a new guide was published on PMDT. PMDT is an abbreviation of the Programmatic Management of Drug Resistant TB. It promotes full integration of basic TB control & PMDT activities under the RNTCP. It is a very comprehensive document and more details are available on drug resistant TB India. The management of drug resistant TB is now to be as set out in the PMDT, and replaces the guidance set out in the Technical & Operational Guidelines. But the treatment of drug sensitive TB is still as set out before.

National Strategic Plan (NSP) for India 2017 - 2025

One of the main changes in this strategic plan 6''National Strategic Plan 2017-2025 for TB Elimination in India", 2017, Government of India, National Strategic Plan 2017-25 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.

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 years of the NSP are completed? Only time will tell as progress is monitored through a series of impact indicators and outcome indicators. To see the first of these please go to National Strategic Plan 2017-2025.

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This page was last updated in September 2020.
Author Annabel Kanabus

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