India has the highest burden of TB in the world, an estimated 2 million cases annually. This accounts for approximately one fifth of the global incidence of TB.
It is estimated that about 40% of the Indian population is infected with TB bacteria. The vast majority of infected people have latent TB rather than active TB disease. It is also estimated by the World Health Organisation (WHO) that 300,000 people die from TB each year in India.
TB care in India is provided by the government’s Revised National TB Control Programme (rntcp) as well as through private sector health facilities.
For the 12th five year plan for 2012 – 2017, the vision of the government was for a TB free India, through achieving Universal Access by provision of quality diagnosis and treatment for all TB patients in the community.
The overall budget required in 2012 – 2017 to achieve this Universal Access vision, to save 750,000 lives from TB, and to control MDRT TB, was estimated to be Rs. 5825 crore ($1.17 billion) over the period 2012 – 2017. However, the Planning Commission of India has so far only approved Rs. 4500 crore ($900 million). These budget cuts have been widely criticised and in Januray 2015 a warning letter was submitted to the government signed by TB officers of all states and Union territories. One doctor said:
“There is always a shortage of TB drugs, lack of labs, slow diagnostic tools, inadequate management of treatment and lack of trained personnel. Moreover, since we have failed to give the existing staff their salary dues they are demoralised”1Srivastava, K, “TB epidemic looms large with Rs 2,000 crore fund cut, erred policy”, dna, 10 January, 2015 www.dnaindia.com/
There is more about the RNTCP.
The private sector in India, unfortunately, has been a source of mismanagement of TB and hence of drug resistance. This includes the use of incorrect diagnostics (e.g. blood tests), incorrect regimes and a lack of supervision to ensure all TB patients complete their TB treatment. So every effort is being made to engage the private sector in India and improve the quality of care provided by private practioners.2Pai, M “Formidable killer: drug-resistant tuberculosis”, The Tribune, India, August 6, 2013www.tribuneindia.com/2013/
There is also a lack of regulation for over the counter drugs for TB and this contributes to the problems of drug resistant TB. There have been calls for the Indian government to do more to educate patients about the appropriate tests and the right treatment for TB.3Udwadia, Z “This should not exist”, Hindustan Times, November 27, 2012 www.hindustantimes.com/
The RNTCP has tried to involve non public health providers in promoting TB care, but it is believed that many patients continue to seek treatment elsewhere and currently go unreported. A number of studies and surveys of TB prevalence including self reporting of TB prevalence, have suggested that up to 46% of patients may not be currently reported.4Satyanarayana, S “From where are Tuberculosis patients accessing treatment in India? Results from a cross-sectional community based survey of 30 districts”, PLoS ONEwww.plosone.org/article/info:doi/10.1371/journal.pone.0024160
There are are many reasons why people in India seek care from the private sector. These include:
“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.”5Bhalchandra Chorghade “To fight MDR-TB, act on time”, http://dnasyndication.com/dna/MUMBAI/
In 2014 the Ministry of Health and Family Welfare started a pilot project in Mumbai to provide patients in the private sector with free treatment. Since the scheme started in August 2014 some 10,675 new patients have registered under the scheme of whom 656 are patients with multi drug resistant TB.
Under this scheme, called the Private Practitioner Agency (PPIA), if a patient goes to a doctor who is registered with the PPIA and they are diagnosed with TB, then:
the doctor issues them vouchers for x-ray and medicines. The chemists and labs provide free medication or diagnostic tests when the patient produces the voucher
The government then reimburses the chemists and labs. Under the program a patient only has to pay the private doctor’s consultation fee.
One drawback of the scheme however, is that it only caters for first line TB treatment. Multi drug resistant TB patients still have to register with the RNTCP in order to get free treatment. As TB treatment takes a long time it has been realised that free medicines are necessary if people are not going to abandon their treatment.
The scheme has been so successful in Mumbai that it has already been started in Nagpur and it is going to be started in a number of other cities as well.6Barnagarwala, T “Free TB treatment plan a hit in Mumbai, ministry to replicate project in other cities, Indian Express 2015, Mumbai-free-tb-treatment-plan-a-hit
With the aim of improving the collection of patient care information, in May 2012 India declared TB to be a notifiable disease. This means that in future all private doctors, caregivers and clinics treating a TB patient must report every case of TB to the government.7Sinha, K “Finally, tuberculosis declared a notifiable disease”, The Times of India, May 9, 2012 //articles.timesofindia.indiatimes.com/2012-05-09/india/31640562_1_mdr-tb-tb-cases-tb-diagnosis
Comments made in response to this move included concerns about enforcement of notification by private practioners;
“This is definitely a positive step forward. But, I am skeptical about the practical possibility in implementing the policy. Most private practioners consider themselves unaccountable to the government. .. The government should be clear about the action that will be taken in case of non compliance of the private practioners.”
There was also concern about whether when people are referred to the RNTCP from the private sector there would be a good enough service, and whether in practice treatment would be available.
A year later it appeared that the concern about whether all patients would be notified was justified, as it was said that:8“Two suspected cases of resistant TB strain in Bhopal”, The Hindu, May 28, 2013www.thehindu.com/health/medicine-and-research/guidelines-for-tuberculosis-notification-sent-out/
“A year after TB patient reporting to the government has been made mandatory for private practioners and hospitals, most cases are going unreported.”
Dr Kl Sahu, State TB officer, Madhya Pradesh
According to Indian government data of the estimated 90,000 TB cases handled by private doctors, only 5,000 were reported in Madhya Pradesh. However, in other parts of India although there was a slow start to reporting there were beginning to be improvements. In Pune there have been 727 new TB cases reported by private hospitals and clinics between May 2012 and July 2013.9“Private hospitals report 700 TB cases”, The Times of India, August 19, 2013http://articles.timesofindia.indiatimes.com/2013-08-19/pune/
“Initially the response was poor but now, with constant follow-up, private doctors and hospitals have started notifying us of the TB cases”
S T Pardeshi, Medical officer of health, Pune Municipal Corporation
More than 1.5 million people currently receive free drugs at the 13,000 Indian government centres across the country. In June 2013 it was reported that shortages were occurring particularly of the paediatric doses used to treat children with TB. Some clinics were apparently turning away sick children, whilst others were carrying out the risky process of splitting adult pills.10Anand, Geeta “Shortages of Drugs Threaten TB Fight”, The Wall Street Journal, 6 June 2013online.wsj.com/article/ G. R. Khatri, the former head of India’s Central TB division, called the paediatric shortages “disastrous”.
In addition to paediatric dosages being in short supply, the central government was also unable to provide sufficient quantities of the TB drugs rifampicin, streptomycin and kanamycin. However the shortages of adult dosages was apparently solved by letting states buy the medicines themselves from private suppliers, and making emergency purchases.
Mario Raviglione, the head of the WHO’s TB department, said that India’s problem is surprising because Indian drug makers supply the vast majority of the world’s TB patients. “In India this shouldn’t happen,” he said “You are a producer of drugs.”
TB India 2014 Revised National TB Control Programme Annual Status Report, New Delhi, 2014 www.tbcindia.nic.in/documents.html#
Revised National Tuberculosis Control Programme DOTS-Plus Guidelines, 2010 www.tbcindia.nic.in/DOTSplus.html
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|1.||↑||Srivastava, K, “TB epidemic looms large with Rs 2,000 crore fund cut, erred policy”, dna, 10 January, 2015 www.dnaindia.com/|
|2.||↑||Pai, M “Formidable killer: drug-resistant tuberculosis”, The Tribune, India, August 6, 2013www.tribuneindia.com/2013/|
|3.||↑||Udwadia, Z “This should not exist”, Hindustan Times, November 27, 2012 www.hindustantimes.com/|
|4.||↑||Satyanarayana, S “From where are Tuberculosis patients accessing treatment in India? Results from a cross-sectional community based survey of 30 districts”, PLoS ONEwww.plosone.org/article/info:doi/10.1371/journal.pone.0024160|
|5.||↑||Bhalchandra Chorghade “To fight MDR-TB, act on time”, http://dnasyndication.com/dna/MUMBAI/|
|6.||↑||Barnagarwala, T “Free TB treatment plan a hit in Mumbai, ministry to replicate project in other cities, Indian Express 2015, Mumbai-free-tb-treatment-plan-a-hit|
|7.||↑||Sinha, K “Finally, tuberculosis declared a notifiable disease”, The Times of India, May 9, 2012 //articles.timesofindia.indiatimes.com/2012-05-09/india/31640562_1_mdr-tb-tb-cases-tb-diagnosis|
|8.||↑||“Two suspected cases of resistant TB strain in Bhopal”, The Hindu, May 28, 2013www.thehindu.com/health/medicine-and-research/guidelines-for-tuberculosis-notification-sent-out/|
|9.||↑||“Private hospitals report 700 TB cases”, The Times of India, August 19, 2013http://articles.timesofindia.indiatimes.com/2013-08-19/pune/|
|10.||↑||Anand, Geeta “Shortages of Drugs Threaten TB Fight”, The Wall Street Journal, 6 June 2013online.wsj.com/article/|