End TB in In­dia to boost its health diplo­macy pro­file

Mint ST - - SCIENCE -

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 casefind­ing 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 pub­licpri­vate 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.

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