Sixty-eight percent of the global Tuberculosis cases are concentrated in South-East Asia and Africa. Surprisingly, India accounts for 27 percent of the world’s cases.
Tuberculosis (TB) is considered as one of the deadliest infectious communicable diseases on our planet. It is caused by bacteria that lead to infections in the lungs and affect other parts of the body. The active TB is spread by airborne particles and the affected person shows chronic cough, fever and weight loss.
According to WHO Tuberculosis report 2019, approximately 10 million people were afflicted with TB and 1.2 million TB deaths occurred in 2018 globally. Sixty eight percent of the TB cases are concentrated in South-East Asia and Africa. Surprisingly, India contributes 27 percent of the cases globally.
The above stats underline the gravity of the disease across the globe and developing countries specifically. However, TB is curable and preventable. The puzzling question before the policy makers is that despite being curable, why many countries have been struggling to eradicate it.
To make sense of TB, it is imperative to understand the socio-economic as well as political conditions under which the disease exists. The contextual understanding helps policy makers to figure out the impediments: whether it is the policy design or policy implementation.
Tuberculosis in India is considered a silent epidemic. It is estimated that TB kills two Indians every three minutes. The efforts to tackle TB can be traced to pre-independence time. During the early twentieth century, missionaries used to build sanatoriums that provided separate medical facilities for TB patients. Later, British India joined the International Union Against TB. Post- independence, the Indian government established a separate TB Division within the Directorate General of Health Service of the Ministry of Health to oversee the plan. India also established new TB research centres in Chennai and Bengaluru in the 1950s and started the National TB Control Program (NTP) in the 1960s. The NTP was revised as DOTS strategy in 1997 which also became a flagship component under the National Rural Health Mission in the 2000s. Earlier, the TB cases came from rural areas but due to rapid urbanisation and consequently poor hygiene conditions in slums and crowded urban areas led to the disease catching on among the urban poor. The government has revised its strategy to broaden the program as National TB Strategic Plan (2017-2025). It involves private sector, civil society and NGO partners.
Impediments to TB eradication
India is a country of the size of a subcontinent with 1.3 billion population and a vast diversity in terms of language, geography, density and cultures. In order to eradicate TB, India adopted a decentralised approach. Under the TB control programme, the district is selected as a unit of administration to tackle TB. There is a District TB Control Society with a District TB Control Officer to monitor and evaluate TB programme. There are TB units at sub-district level that cover approx. 5 lakh people.
However, there are various underlying factors that also make conditions conducive for transmission of TB. The high population density, poor hygiene in urban and rural space, weak health capacity and gap in communication outreach make things difficult to eradicate TB at a faster rate.
The challenges in eradicating TB
- Lack of last mile delivery: Despite a decentralised approach of establishing TB units at sub-district and district levels, the TB control program is hampered by the lack of last mile delivery. Most of the affected TB patients are daily wagers and can’t afford to visit the specialised centres for treatment and diagnosis. The nature of treatment of TB requires long duration of visits that make the treatment service costly to patients. There is also a correlation of poverty and prevalence of TB cases. Without decreasing the cost of treatment in terms of transport, visits and accessibility to TB units, the eradication of TB can’t be imagined.
- Stigma and myths: According to government estimates, stigma associated with TB leads to 3 lakhs children dropping out of schools annually. The stigma not only leads to psychological impact on the patient but also hinders the reintegration of the affected person into the society. It also deters TB patients to continue and report the disease. India has been witnessing the rise of Multidrug Resistance (MDR) and XDR- TB with stigma as one of the factors of non-continuation of medication.
- Weak public health system: Indian public health system is rife with quacks and dependent on private healthcare. The affected person usually goes to quacks due to their easy accessibility. However, informal treatment can lead to complication of the disease and sometimes even cause death. On the other hand, the Indian public health system remains stagnant as the government spends approximately 1 percent of its GDP on public health. Over-dependence on the private sector has led to an increase in the cost of treatment.
- Lack of tech and evidence-based approach: Due to poor accountability structure and audit system, there has been issue of inaccuracy, human error and unreported cases of TB. The lack of tracking the patient’s treatment has led to failure in detection of default rate.
- COVID crisis adds to the challenge:. Following the advent of Covid-19 pandemic in 2020, India reported a decrease in the reporting of TB cases. The reasons were the inaccessibility of TB centres, diversion of medical infrastructure and health workers to deal with the COVID crisis. The disruption of TB treatment services led to discontinuation of TB doses and risked the increase in drug resistant cases.
Despite staggering challenges in eradication of TB, there is a cause for hope. One of the successful models to tackle the disease is Operation ASHA in India and Cambodia. Their results are very encouraging. The model is community-driven, incentive based and tech driven. The Operation ASHA has shown amazing results: There has been an 87 percent treatment success rate. The detection rate has also gone up and significantly the cost of treatment has come down to $80 per patient as compared to $852 by other organisations.
The following approach and strategy can be executed in India to eradicate the disease:
- Community driven approach: It is a potentially transformative approach to deal with TB in India. Local community health workers can be trained, engaged and involved in detection, treatment and counselling of TB patients. It is the most effective and sustainable approach as it reduces the cost of treatment in terms of visits and familiarity with local customs. Local community workers can use their own culture and custom as a cultural resource to remove stigma related to TB. It also creates jobs for local people and leads to community ownership of the program
- Incentive based approach: It is important to realise that individuals respond with incentives and disincentives. The local community workers can be rewarded for their work. This brings competition in the program among the health workers. Various incentives and disincentives at the government level can be explored to drive efficient results.
- Leveraging technology: Today, technology provides a promising opportunity in detection, monitoring and treatment of TB patients. Low cost and high impact technology such as digital tablets, fingerprinting, GPS can be leveraged to collect data that can be used for compliance, attendance and alerting the TB patient. Government has also introduced the Nikshay portal for monitoring TB patients. The data-driven governance is needed in eradication of TB as it aids in analysing the weak links in the intervention and helps in course correction. The government can leverage technology to do DBT in beneficiary accounts.
- Better scientific research: In MDR (Multi-Drug-Resistant TB) and XDR (Extensively Drug-Resistant TB) cases, there is a need to expedite the efforts to rejig the drugs and medicines. The research and development hold the key in treatment of drug resistant TB cases as TB bacteria mutates geographically and with time.
- The present COVID crisis presents an opportunity for policy makers to invest in the public health system. TB has remained a silent and neglected epidemic. COVID crisis has alerted the countries about the importance of investment in health. Post-COVID strategy must be to invest in robust public health infrastructure.
TB remains a public health emergency for India. The war against the disease can be won if it involves community participation, government intervention, partnership with private sector and civil society organisations.