Fighting India’s silent epidemic

ECONOMIC AND CLINICAL CRISIS: There are 2.2 million new cases and close to 3,00,000 deaths each year according to the Government of India’s TB India 2014 report. Picture shows the x-ray of a patient in New Delhi suffering from both TB and HIV.

Tackling TB requires both strengthening the public sector and engaging the private sector

Over 60 per cent of all Indians seek health care in the private sector according to India’s last National Family Health Survey. This undoubtedly makes the private sector the largest provider of health services in India. The government health system, though vast and well-intentioned, continues to be overburdened with multiple challenges including long waiting hours, an ageing infrastructure, limited funding and human resources. Even though parallel providers of health services, the absence of partnerships between the public and private sector has disastrous implications for patients and for disease control. A striking case study is that of TB.
With 2.2 million new cases and close to 3,00,000 deaths each year, TB is India’s silent epidemic. The 60 per cent of all TB patients who first go to the private sector receive care whose quality varies enormously, often leading to delays in diagnosis and no assurance of cure. As a result, a large proportion of these patients move — sicker and poorer — from one provider to another, infecting others in the process.
Treatment access and reliability

While TB can affect anybody, studies have shown that it is four times more common in people in the lowest socio-economic quintile compared to the highest. A recent systematic review found that the total costs of TB for patients and affected families on average corresponded to more than half their yearly income. This makes it a clinical as well as an economic crisis.

How can India address this crisis? Tackling TB in India requires both strengthening the public sector and engaging the private sector. For a disease like TB, early diagnosis and correct treatment are the easiest ways to reduce transmission. India needs to give every patient, irrespective of whether they go to the public or private sector, access to quick and reliable diagnosis and treatment.
 Studies have shown that TB is four times more common in people in the lowest socio-economic quintile compared to the highest 
For the government, this means that every primary health centre (urban and rural) — the first point of care for the patient — should be capable of making a diagnosis of TB and initiating treatment.
For this, diagnostic facilities need to be upgraded and clinical and laboratory staff given training. Private services could be utilised for some of these investigations in PHCs where these facilities may not be available (for example imaging studies, paediatrician opinions and rapid molecular tests). Patients should not need to travel long distances to get a diagnosis.
Ultimately, the quality of health care provided and a “satisfied client” are the most successful advertisements for the health system. At the same time, we must actively engage the private sector in a mutually acceptable way — while patients continue to remain with the individual doctor, both diagnosis and treatment could be provided free through the public sector.
Brazilian example

Here, Brazil offers an excellent example, where TB drugs are offered only by the public health system and are unavailable in the private sector. TB drugs are bought through a centralised mechanism of acquisition and distribution, ensuring drug quality.

Such a model could easily work in India if combined with effective use of technology. Each patient diagnosed in the private sector could avail drugs through the use of a paper or electronic voucher valid at designated pharmacies. This would ensure that patients receive appropriate and quality-assured drug regimens reducing patient costs. Further, it would ensure notification of all patients and help in monitoring and follow-up to ensure cure.
There is obvious reluctance in the private sector to engage with the government because of the fear of losing their patients, excessive monitoring, delayed payments, etc. Hence, we must be flexible in our approach to treatment (as long as standards are followed) and create more transparency, accompanied by use of technology to address systemic delays.
Changes in TB programme

Rapid reduction in TB burden is not possible without significant changes in India’s TB programme. It requires uniform and equitable implementation of the diagnostic, treatment, public health and social support guidelines laid down in the Indian Standards of TB care, strengthening of human resources both at the Central and State level, using novel methods of monitoring patient compliance (e.g. mobile phone based) and launching a massive public awareness campaign. Procedures for procurement and distribution of drugs need to be streamlined to ensure a constant supply of quality-assured drugs. More flexibility in programme delivery needs to be given to State and district-level implementing officers. Alongside inputs to achieve universal health coverage, social protection interventions that address out-of-pocket expenses and the food and nutritional requirements of TB patients are also critical — an innovative example is the free breakfast scheme for TB patients launched by the Chennai Corporation.

India may take a cue from China, where TB prevalence declined by half as the government invested heavily in systemic improvements, modernisation and changing approaches to diagnosis and treatment. This revitalisation of TB services led to millions being able to access timely, high-quality TB treatment which considerably reducing the number of new TB cases.
India urgently needs similar investment in the health system combined with innovative strategies to address TB and drug resistant TB.
In 2013, the World Health Organization identified 3 million missing TB cases globally of which 1 million were in India. These 1 million missing cases fall somewhere between the public and the private sector and lack access to free care. If India wishes to end its TB crisis, we must begin by providing prompt diagnosis and treatment to our missing million. Yet this is unlikely to happen unless we transform our current TB programme while simultaneously engaging the vast private sector. If we do not act now, our inaction will make us responsible for continued suffering of patients and deaths.
(Soumya Swaminathan is director, National Institute for Research in Tuberculosis, Chennai, and Chapal Mehra is an independent New Delhi-based writer.)

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