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TB in India – TB burden, NSP, private TB care

TB Burden in India

Each year about 2.2 million people develop TB in India and an estimated 220,000 die from the disease.1“TB India 2016 Revised National TB Control Programme Annual Status Report”, New Delhi, 2016 www.tbcindia.nic.in Some estimates calculate the deaths as being twice as high. TB can affect any age, caste or class but cases are mainly poor people. Slum dwellers, tribal populations, prisoners and people already sick with compromised immune systems are over-represented among the cases, compared to their numbers in the population. The economic burden of TB is extremely high. Between 2006 and 2014, TB cost the Indian economy a massive USD 340 billion.

Calls for improved treatment & care for TB in India

Calls for improved treatment and care for TB in India

TB treatment & care in India is provided by the government’s Revised National TB Control Programme (RNTCP) as well as through private sector health providers. In 2015 the RNTCP covered a population of 1.28 billion. A total of 9,132,306 cases of suspected TB were examined by sputum smear microscopy and 1,423,181 people were diagnosed and registered for TB treatment.2“TB India 2016 Revised National TB Control Programme Annual Status Report”, New Delhi, 2016 www.tbcindia.nic.in There are some more TB statistics for India.

TB Case notification

The notification of TB cases is estimated to be only 58%. Over one third of cases are not diagnosed, or they are diagnosed but not treated, or they are diagnosed and treated but not notified to the RNTCP. This could be even higher, and the WHO (World Health Organisation) estimates that possibly as many as another 10 lakh (1,000,000) Indians with TB are not notified.

One of the reasons for the low case notification is the largely unregulated and unmonitored private sector which accounts for almost half of the TB care delivered in India.

National Strategic Plan (NSP) 2012 -2017

For the five year National Strategic 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. This was a major policy change.

The policy change meant extending the reach of RNTCP services to all people diagnosed with TB, including those with drug resistant TB, as well as those seeking treatment in the private sector. The new policy also included improving the quality of existing RNTCP services.

The aim was to achieve the following targets by the end of 2015:

  • early detection and treatment of at least 90% of estimated TB cases in the community, including HIV associated TB
  • initial screening of all previously treated (retreatment) smear-positive TB patients for drug resistant TB and the provision of treatment services for multi drug resistant TB
  • the offer of HIV counseling and testing for all TB patients, and linking HIV infected TB patients to HIV care and support
  • successful treatment of at least 90% of all new TB patients, and at least 85% of all previously treated TB patients
  • the extension of RNTCP services to patients diagnosed and treated in the private sector.

Activities to achieve these targets

The RNTCP planed to achieve these targets by:

  • using rapid diagnostics for the diagnosis of TB and drug resistant TB
  • expanding services for the management of multi drug resistant TB
  • strengthening urban TB control
  • strengthening public-private mix initiatives
  • improving the quality of basic DOTS services
  • aligning with National Rural Health Mission supervisory structures.

The Standards for TB Care in India was produced to help ensure a successful standard of diagnosis and treatment.

The Standards for TB Care in India (STCI)

The Standards for TB Care in India is based on other international guidelines and standards. It was developed by a large number of organisations and individuals, both within and outside of the Government of India (GOI). It was first published by the World Health Organisation in 2014. The Standards describe what should be done, and the TB treatment and care that should be provided throughout India, including what should be provided in the private sector.

Making TB a notifiable disease in India

In May 2012 India declared TB to be a notifiable disease. This was done with the aim of improving the collection of patient care information. It meant that in future all private doctors, caregivers and clinics treating a TB patient had to report every case of TB to the government.3Sinha, 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.

Private sector care for TB

The private sector in India, has unfortunately, 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.4Pai, M “Formidable killer: drug-resistant tuberculosis”, The Tribune, India, August 6, 2013www.tribuneindia.com/2013/
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.5Satyanarayana, S “From where are Tuberculosis patients accessing treatment in India? Results from a cross-sectional community based survey of 30 districts”, PLoS ONE www.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:

  • poor knowledge about TB
  • poor knowledge about services available through the national programme
  • the convenience of services
  • a desire for confidentiality
  • a desire for personalized care.

“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.”6Bhalchandra Chorghade “To fight MDR-TB, act on time”, http://dnasyndication.com/dna/MUMBAI/

Free TB treatment for patients in private sector

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.7Barnagarwala, 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

More TB information

There is more about the Testing & Diagnosis of TB in India, TB Treatment in India, and Drug Resistant TB in India.

Major Sources for TB in India

Draft 2015 report on Indian Revised National TB Control Programme from Joint Monitoring Mission www.tbonline.info/media/uploads/documents/jmmdraft2015.pdf

Revised National Tuberculosis Control Programme Guidelines on Programmatic Management of Drug Resistant TB (PMDT) in India www.tbcindia.nic.in

Revised National Tuberculosis Control Programme National Strategic Plan 2012-2017

Standards for TB Care in India www.tbcindia.nic.in

TB India 2016 Revised National TB Control Programme Annual Status Report, New Delhi, 2016 www.tbcindia.nic.in

References

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1. “TB India 2016 Revised National TB Control Programme Annual Status Report”, New Delhi, 2016 www.tbcindia.nic.in
2. “TB India 2016 Revised National TB Control Programme Annual Status Report”, New Delhi, 2016 www.tbcindia.nic.in
3. 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
4. Pai, M “Formidable killer: drug-resistant tuberculosis”, The Tribune, India, August 6, 2013www.tribuneindia.com/2013/
5. Satyanarayana, S “From where are Tuberculosis patients accessing treatment in India? Results from a cross-sectional community based survey of 30 districts”, PLoS ONE www.plosone.org/article/info:doi/10.1371/journal.pone.0024160
6. Bhalchandra Chorghade “To fight MDR-TB, act on time”, http://dnasyndication.com/dna/MUMBAI/
7. 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