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TB in India – Elimination, Private Care, TB burden, NSPs

The Elimination of TB in India

In March 2017 the Government of India (GoI) announced that the new aim with regard to TB in India was the elimination of TB by 2025.

“Ensuring affordable and quality healthcare to the population is a priority for the government and we are committed to achieving zero TB deaths and therefore we need to re-strategize, think afresh and have to be aggressive in our approach to end TB by 2025” Shri J P Nadda, Union Minister of Health and Family Welfare1“Shri J P Naddda launches new initiatives to combat TB”, 2017, http://medicalnewsindia.com/govt-committed-achieve-zero-tb-deaths-says-health-minister

Elimination as defined by the World Health Organisation (WHO), means that there should be less than 1 case of TB for a population of a million people. In view of the current TB burden in India, there is a great deal that needs to be done if elimination is to be achieved by 2025.

Shortly after the announcement of the aim of elimination, the GoI published the new National Strategic Plan 2017 – 2025, setting out how it plans to achieve the elimination of TB in India.

TB Burden in India

India accounts for about a quarter of the global TB burden as shown below.

In 2016 an estimated 28 lakh cases occurred and 4.5 lakh people died due to TB. 2“Global TB Report 2017”, WHO, 2017

Estimated burden of TB 2016
Estimates of TB burden (2015) Global India
Incidence of TB cases 104 lakh (10.4 million) 28 lakh (2.79 million)
TB mortality 14 lakh (1.4 million) 4.35 lakh (435,000)
Incidence of HIV/TB 11.7 lakh (1.17 million) 1.1 lakh (110,000)
Mortality of HIV/TB 3.9 lakh (390,000) 12,000
MDR TB 4.8 lakh (480,000) 0.84 lakh (84,000)

In 2016, and as a result of new information being available, the GoI together with the World Health Organisation revised upwards the estimates for the burden of TB in India.

Worldwide India is the country with the highest burden of both TB and MDR TB.3“Global TB Report 2017”, WHO, 2017 There are an estimated 79,000 multi-drug resistant TB patients among the notified cases of pulmonary TB each year.

India is also the country with the second highest number (after South Africa) of the estimated HIV associated TB cases. For more see TB & HIV in South Africa.

Private & Public Care

Free TB treatment is available at all government health centres in India

Free TB treatment is available at all government health centres in India

TB treatment & care in India is provided in the public sector by the government’s Revised National TB Control Programme (RNTCP) as well as through private sector health providers. The private sector is very large, and it is believed that more than half of all TB patients are cared for in the private sector.

In 2016 the RNTCP notified 17.5 lakh TB patients from both the private and public sector. Of these some 3 lakh patients were from the private sector but it was estimated that a further 15 lakh patients in the private sector were not notified and were seeking care outside the public sector.

There were also 33,820 patients notified who had drug resistant TB. However, these are still only preliminary revisions and more changes are quite possible when India conducts its first national TB prevalence survey in 2017 – 2018.

There are many reasons why people in India seek care from the private sector. These include:

  • poor knowledge of TB;
  • poor knowledge of services available through the national public program;
  • the convenience of services in the private sector;
  • 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.”

National Strategic Plan 2012 – 2017

There have been a number of five year National Strategic Plans (NSP)s since the start of the RNTCP. This ambitious plan, the NSP 2012 – 2017, had the aim of achieving universal access to quality diagnosis and treatment. Before this there was little treatment available through the RNTCP for the treatment of drug resistant TB.

A number of significant improvements were made during the five years of the plan. These included:

Complete geographical coverage

Calls for improved treatment and care for TB in India

Calls for improved treatment and care for TB in India

Complete geographical coverage for diagnostic and treatment services for multi-drug resistant TB was achieved in 2013. A total of  93,000 people with MDR TB were diagnosed and had been given treatment for drug resistant TB by 2015. Also, the National AIDS Control Organisation (NACO) had collaborated with the RNTCP and had made HIV-TB collaboration effective. Most TB patients registered by the RNTCP were receiving HIV screening and 90% of HIV positive TB patients were receiving anti-retroviral treatment.

Banning of sero-diagnostic tests

In June 2012 the GoI prohibited the import and sale of sero-diagnostic tests for TB. It is now believed that this has saved countless people from having inaccurate results. Another government order in May 2012 made it compulsory for health care providers to notify every TB case they diagnosed.  Since TB became a notifiable disease private providers have notified more than 700,000 people but many more people than that are believed to have been treated outside the public sector.

Development of Nikshay

The Central TB Division developed a case based and web based system called “Nikshay”. This helped with the reporting of all TB cases. It was scaled up nationally.

Standards for TB Care in India

The Standards for TB Care in India was also developed and it was published 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.

Reaching the private sector

Despite the improvements that had already been made:

There had continued to be concern about the standard of care provided in the private sector. Delays in diagnosis, the use of multiple non standard regimens for inappropriate lengths of time, the lack of a way to ensure the full course of treatment was being taken, and the recording of treatment outcomes were just some of the issues.

So in 2016 the RNTCP published revised technical and operational guidance. The new guidelines did not replace the previous guidance (the Standards of TB Care in India), but they provide updated recommendations. They also make it absolutely clear that the guidance applies to the private sector as well as the public sector.

The strategic vision of the RNTCP is to lay down guidelines and norms for TB care in the country. So the principle of the RNTCP is that they should extend public services to privately managed patients.

The decision was also made to introduce a daily TB treatment regimen as directed by the Indian Supreme Court. The new anti TB drug bedaquiline for the treatment of drug resistant TB is also to be made available initially in five states.

For diagnosis the GoI has set up more than 600 CB-NAAT laboratories, and has enhanced their capacity with highly sensitive diagnostic services. CB-NAAT is the name given in India to Cartridge Based Nucleic Acid Amplification tests such as  Genexpert and TrueNat.

There is more about TB testing & diagnosis in India and TB treatment in India

National Strategic Plan (NSP) 2017 – 2025

One of the main changes in this strategic plan, is that the emphasis is going to be on reaching patients seeking care from private providers. So this NSP builds on the work already done with the new RNTCP operating guidelines. The RNTCP will also be helping private providers to provide quality care and treatment, rather than encouraging the private providers to send their patients to get care from the RNTCP.

The NSP plans to provide incentives to private providers for following the standard protocols for diagnosis and treatment as well as for notifying the government of cases.4“India’s ambitious new plan to conquer TB needs cash and commitment”, The Conversation,  October 4, 2017 https://theconversation.com/indias-ambitious-new-plan-to-conquer-tb-needs-cash-and-commitment-84821 Also patients referred to the government will receive a cash transfer to compensate them for the direct and indirect costs of undergoing treatment and as an incentive to complete treatment. This has already been trialed in some pilot projects.

“When I visited the largest slum in Mumbai with over one million people, I saw a model of care that seems to work whereby private practioners are empowered to detect and report TB cases through the support of an NGO and patients are mobilized to access TB services through the incentive of vouchers” Dr Mario Raviglione, Director WHO Global TB Programme 5“India on the right path to ending TB”, World Health Organization, 2016, www.searo.who.int/india/mediacentre/events/2016/

The cost of implementing the new NSP is estimated at US$ 2.5 billion over the first three years. This is a large increase over the budget for the current NSP.

The work set out in the National Strategic Plan has been arranged in four strategic areas, which can be described as:

  • Detect
  • Treat
  • Prevent
  • & Build

You can read more about the National Strategic Plan 2017 – 2025

You can also read more about TB by looking at

The Testing & Diagnosis of TB in India

TB Treatment in India

TB statistics

Major Sources for TB in India

Revised National Tuberculosis Control Programme National Strategic Plan 2012-2017 (pdf)

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

TB India 2017 Revised National TB Control Programme Annual Status Report, New Delhi, 2017 www.tbcindia.nic.in

References

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1. “Shri J P Naddda launches new initiatives to combat TB”, 2017, http://medicalnewsindia.com/govt-committed-achieve-zero-tb-deaths-says-health-minister
2. “Global TB Report 2017”, WHO, 2017
3. “Global TB Report 2017”, WHO, 2017
4. “India’s ambitious new plan to conquer TB needs cash and commitment”, The Conversation,  October 4, 2017 https://theconversation.com/indias-ambitious-new-plan-to-conquer-tb-needs-cash-and-commitment-84821
5. “India on the right path to ending TB”, World Health Organization, 2016, www.searo.who.int/india/mediacentre/events/2016/