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‘Tuberculosis Control in India: Time to get ambitious and innovative’

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On the eve of World TB Day, Dr Madhukar Pai, a professor based at McGill University, Montreal, and Co-chair of the Stop TB Partnership’s New Diagnostics Working Group, writes on the challenges ahead for fighting TB in the next phase of the Revised National TB Control Programme RNTCP 3 (2012-2017). JATB is honoured to feature him.

With 2 million new cases annually, India carries the largest TB burden in the world – one-fifth of world’s new cases. A substantial change in reducing TB here in India, means a change in the TB burden the world over.

India began implementing the WHO recommended DOTS (Direct Observed Treatment Short course) strategy in 1997 as part of the Revised National TB Control Program (RNTCP) led by the Central TB Division of the Ministry of Health. The Government of India is currently in the process of preparing the blueprint for RNTCP 3 which will run from 2012-2017.

If we take a look at the programme’s achievements during its first two phases, the RNTCP is to be commended for the role it played in India successfully scaling up DOTS to cover 100% of the population. This scale up made India’s DOTS programme the world’s fastest expanding health programme. We’ve done well to achieve international targets for case detection (70%) and cure rates (85%) and it’s been cost-effective, with exceptional return on investment from a societal perspective. Yet, in 2009, over 2 million TB cases and 280,000 TB deaths keeps India at the top of the list of countries with the highest TB burden. It is obvious that we are not succeeding in this battle. And a primary reason for this is poor diagnosis and mismanagement of TB. Diagnostic delays are all too common and by the time a patient is diagnosed with TB, he/she has already visited multiple doctors, and infected several others.

We have the largest private health sector in the world, with 60-80% of health care in India falling under the private sector. Private providers are the first point of care for the vast majority of TB cases and yet are estimated to contribute just 2%-3% of RNTCP case finding and less than 1% of case management. Therefore, if RNTCP 3, the third phase of the program, must succeed, the Indian private sector must be incentivised and engaged on a scale commensurate with its dominant role. Small-scale projects are just not adequate. The need of the hour is socially-oriented yet economically viable, innovative business models that combine public and private financing. Indian corporate donors and philanthropists must step up to support the RNTCP. The motive is as business driven as it is altruistic because TB takes its toll on young and working adults in India, resulting in mammoth economic losses.

Despite its size and importance, the Indian private sector is largely unregulated, characterized by systemic market failures throughout the value chain. These include dumping of useless diagnostics from rich countries into India because of weak regulation, doctors receiving kickbacks for tests ordered, over-reliance on bad tests and under-use of good diagnostics and prescription of incorrect TB treatment regimens. A recent study from Mumbai, by the Hinduja Hospital, published in Public Library of Science, showed 106 doctors prescribing 63 different drug combinations for TB. Such irrational practices may explain the emergence of 100,000 drug-resistant TB cases each year in India.

The socio-political aspect of this problem in India was poignantly illustrated by Michael Specter in the New Yorker recently, where he provided heartbreaking stories of mismanagement of TB in India. A particular case in point was the market for inaccurate and inappropriate TB diagnostics, particularly in the private sector. Serological (antibody) blood tests for TB are known to be inaccurate and inconsistent yet despite the evidence and lack of any supporting policies, a whopping 1.5 million TB serological tests are done in India every year. The market size for this undependable test? At least Rs. 70 crores (15 million US $) per year.

Mismanagement of TB is detrimental at two levels – at that of the individual patient who may be put on unnecessary TB therapy or continue to suffer from TB without the correct treatment and at the level of public health because every mismanaged or undiagnosed TB patient serves as a source for new infections in the community. Breaking this chain of transmission requires the earlier and faster detection of the disease and getting more TB patients on the correct therapy.

To improve the landscape of TB diagnosis, India must adopt new tools that are accurate, validated and WHO-endorsed, and replace bad tests with ones that can reduce the spread of TB in the community. This will require improvements in regulation of the private sector in general and an intense review of regulation of diagnostics to prevent abuse of suboptimal diagnostics. In addition, ambitious goals must be set. India has already taken the lead in this area, with its impending launch of RNTCP 3, by envisioning an ambitious plan for 2012-2017, that aims to provide universal access to quality diagnosis and treatment for the entire population.

That the RNTCP alone cannot make this vision a reality is a given. It demands that a role be played by all the stakeholders in what is essentially a national problem. Along with the Indian government which must fund this with the substantial resources that the plan needs, the Indian private sector and industry also has a unique opportunity here. India already makes a remarkable contribution through low-cost generic drugs and it certainly has the capacity to develop low-cost generic or novel TB diagnostics that can make a big difference, both nationally and internationally. Indian generic anti-viral drugs dramatically changed the global landscape of access to HIV treatment and similar efforts are underway to develop low-cost flu diagnostics, vaccines and drugs. TB deserves the same dedicated focus from various stakeholders.

The time has come for all Indian healthcare providers, industry, civil society, donors, activists, journalists, politicians, philanthropists and patient groups to rally behind RNTCP 3 and make it a success story. Having made major inroads in improving TB control, it is now time to get ambitious and innovative. Anything less will not save the thousands still dying of TB every day.

This article was originally published as an Op-Ed in The Asian Age on 23 March 2011 (New Delhi edition).

Written by JournalistsAgainstTB

March 23, 2011 at 3:32 pm

Posted in TB and Media

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