India’s tuberculosis (TB) burden is staggering. The country accounts for over a quarter of the global TB burden, and has the second highest estimate for HIV associated TB cases.
The Revised National Tuberculosis Control Program (RNTCP) has treated over 20 million patients in India since its inception in 1997. However, the government revised the national tuberculosis estimates upwards in 2016 based on evidence from one statewide prevalence survey, studies of tuberculosis drug sales in the private sector, evidence of huge under-notification, and more accurate national mortality data.
The policy on mandatory TB notification from private sector providers to capture “missing cases” and the case-based TB notification system ‘NIKSHAY’ resulted in a 35% rise in notifications between 2013 and 2015. This further underscore the challenge of TB cases being treated outside the national program.
Recognizing the severity of the problem, Prime Minister Narendra Modi launched last month the Tuberculosis Free India Campaign at the opening of the Delhi End TB Summit, presenting his vision to end the disease by 2025. He stated in his address that India needs reinvigorated efforts and a change in approach toward eradicating the disease.
The strong political commitment comes amid a charged global agenda to end TB by 2030, re-galvanized at the Global Ministerial Conference in Moscow in November 2017. The campaign will gain further traction at the upcoming UN General Assembly high-level meeting on TB in New York in September.
India’s vision to end TB by 2025 is 5 years ahead of the 2030 target set by the UN Sustainable Development Goals. But there is reason for optimism, based on elements of the new government program backed by commitment at the highest level.
First, the revised National Strategic Plan (NSP) for TB Elimination 2017-2025 is a crucial step toward recognizing gaps in the previous approach and builds on four strategic pillars of “Detect – Treat – Prevent – Build”. The NSP keeps in view engaging all stakeholders, while adopting a targeted strategy with a significant role for the private sector.
Other key priorities include scaling up diagnostic facilities, such as making the CB-NAAT test available throughout India; plugging the “leak” from the TB care cascade (i.e. people with TB going missing from care) and providing patient support for increasing treatment adherence. The NSP also supports active case finding among key populations and the preventing people with latent TB in high-risk groups from developing active TB.
The NSP likewise calls for a special focus on the programmatic management of drug-resistant TB, and thereby providing quality care for all forms of TB.
Overall, we see that there has been a welcome change in the policies and strategies that could lead to dramatic reduction of India’s TB burden. However, the results would depend on how policies and plans get operationalized at the ground level, and state governments will play an important role.
The second positive step is increased funding. In the 2017 national budget, TB funding has been raised to $525 million from $280 million in 2016. Almost three-quarters of the money comes from domestic sources, with the rest being contributed by the Global Fund, USAID, and other development partners.
However, funding allocation would need to be further enhanced to implement the comprehensive set of strategies envisaged in NSP. Only with sufficient funds and efficient utilization of available resources will the government be able to successfully translate its TB ambition into reality on the ground. It is expected that the cost of implementing the new NSP will be nearly $2.5 billion, as stated in the draft strategy devised by the Ministry of Health and Family Welfare.
Third, improved service delivery in both the public and private sector is a must to fill existing gaps in the cascade of care. About half a million TB patients who reach health facilities face delays in diagnosis and treatment.
Service delivery would benefit from a further scaling up of rapid molecular diagnostics and by making drug susceptibility testing universally accessible, supported by tools for treatment adherence support.
Pilot projects in Mehsana, Mumbai and Patna have shown that notifications from the private sector (which caters to almost half of those treated for TB at some point) can be dramatically increased, with improvements in both quality of services and patient outcomes.
Furthermore, empowering and engaging communities and civil society in planning, monitoring and delivery of services is essential to include hard-to-reach patients, and provide patients with affordable and acceptable quality services. Building on the patient-centered approach, the 2017 budget now includes nutritional support to TB patients during treatment through direct cash transfers.
There has also been a recent move by the government to align the RNTCP with the National AIDS Control Organization (NACO). This will help mobilizing multi-sectoral response and harness the strengths of NACO in engaging with community-based organizations and civil society groups.
Finally, India’s strength in research and technology needs to be leveraged.
Indian biotech and drug manufacturers dominate production of TB and HIV medications, accounting for more than 80% of the global market. The country also has immense capacity in IT and software that could be used for better TB surveillance and treatment adherence, in addition to improving data collection, management and mining to inform effective implementation.
The establishment of the TB Research Consortium in 2016 is a welcome development, indicating a firm commitment to continued excellence in TB research in India. India has taken the initial steps in right direction. The commitment is visible, the policies are in place, and the momentum is building.