In today’s inter-connected world, a nation’s health is no longer an internal matter. This century’s outbreaks, such as Ebola, Zika, and SARS, are jolting reminders of a common threat that transcends boundaries —infectious diseases. Little wonder, health has recently found its way into diplomacy and foreign policy of many countries, evident from the agenda of this year’s G8 and G20 summits.
The Indian government has also demonstrated political will to improve the health security of citizens with two bold announcements. First, an aggressive resolve to end tuberculosis (TB) by 2025, 10 years ahead of the World Health Organization’s (WHO’s) goal; and second, a step towards achieving universal healthcare through the Pradhan Mantri Jan Arogya Yojana (PMJAY), touted as the world’s largest government-sponsored health insurance scheme.
While PMJAY’s uptake will grab media attention, the end result of the End TB programme will make global headlines. While the impact of PMJAY’s performance will largely be contained within India, affecting internal politics and economics, that of eradicating TB will factor heavily into India’s image and influencing power in global health diplomacy networks. This year has seen an Indian clinician-cum-TB activist inducted into WHO’s top management team, a first for India. It was also a sign of India’s precarious position in the world what with the highest TB burden, and the expectations of diffusing that time bomb before it explodes into a global health crisis.
TB is air-borne. With approximately 300 TB patients per 100,000 Indians, the very process of breathing puts one at risk of acquiring the disease in lungs, spine, brain or any other organ. India’s run up to the 2025 deadline requires TB transmission to decline at the rate of 15-20% annually. At present, that seems a difficult task. Even though tests and treatment are available for free across all public health centres, and patients can claim a nutritional incentive of ₹500 per month until fully cured, the current decline rate of TB in India is a worrying 1-2%. What’s even more worrisome is that half of the estimated patients are either unaware that they have TB, or are unreported in the government’s e-registry for TB, Nikshay.
More than a million hidden carriers of active infection live among us, presenting a covert threat. Infected patients infect others in the community while undiagnosed. TB transmission can’t be ended until they are cured. Finding them is the biggest roadblock for the End TB mission, and a rate-limiting one. With that realization, the government’s long-standing Revised National TB Control Programme (RNTCP) has now initiated an active case-finding campaign in selected population segments—those who are socially, clinically or occupationally more vulnerable than others; that is, living or working in shanty towns, prisons, red-light districts and shelter homes, or AIDS patients. The first three phases of this screening identified more than 12,000 new patients who might have remained hidden otherwise. In the rest of the population, the hope is that TB cases will be duly reported and treated.
The doctor-initiated passive approach of case detection has proven to be more daunting than clearing a minefield. Private healthcare providers are the first contact points for more than half of the Indian population. About 50-55% of private practitioners are doctors-by-experience, not degree. This is where the search-and-treat strategy for TB is falling through the cracks. Sarang Deo of the Indian School of Business, with funding from the Bill and Melinda Gates Foundation, is running a large private sector engagement pilot in Mumbai and Patna to study care pathways of TB patients.
“Early symptoms of TB are non-specific, and quite similar to more commonly occurring conditions, such as secondary infections resulting from seasonal flu. Private practitioners rule out other ailments through antibiotic treatment before ordering TB tests. Delayed TB diagnosis is the biggest risk factor for transmission,” he says.
Non-specific antibiotic courses, it should be noted, multiply the risk manifold, causing the infection to become antibiotic-resistant. Another widely prevalent behaviour in the private sector is hesitation to notify and refer their TB patients to public health facilities, despite cash incentives. Fear of permanently losing clients and revenue to the public sector is the biggest reason for non-compliance. To allay their concerns, a new engagement model of public-private partnership is being tested in Mumbai and Patna, wherein private practitioners are encouraged to manage patients themselves, provided they complete e-Nikshay case notification and follow the standard of care treatment protocol.
“Our results suggest that this new model, even though seemingly more effort-intensive, is actually not more expensive on a recurring cost per case basis. However, for cross-country scaling up, the RNTCP budget would have to increase accordingly,” Deo says. The approved budget for 2017-20 is ₹12,300 crore against the requirement of ₹16,600 crore.
Additional budget consideration may pose an uncomfortable challenge for the government. It is, though, unquestionably a fair price to pay for attaining leadership in global health diplomacy. In addition to new provider-focussed strategies, it is time to galvanise the society to drop the fear of stigma, and insist on a TB test, if one’s cough persists for weeks. This is how India got rid of polio.
Eradicating polio was an important step; becoming the first nation to eradicate TB will be a giant leap.
Sheetal Ranganathan is vice-president of life sciences and healthcare operations at a research and consulting firm, and a commentator and columnist covering global health and science.
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