The response to TB in India needs to be set at an unprecedented level with bold ambitions of getting to near zero levels of death and with resource commitments from both the public and private sector that is commensurate with the scale of the problem.
The Government has recently taken a few steps in the right direction, e.g. increasing the budget for Revised National Tuberculosis Control Programme (RNTCP), launch of a mandatory notification policy and a vision to provide universal access. These are important steps, but will need more efforts and partnership with all stakeholders to effectively implement in a diverse country like India. In my view the following seven points are important to address TB and prevent further emergence of drug resistant forms of TB in India:
- Adoption of bold policies, proposed and driven by the civil society and key stakeholders, including the TB-affected communities and the private business sector. Policies should promote universal access to care for all forms of TB in adults and children, including drug-resistant TB and HIV-associated TB. This should include provision of universal access to drug susceptibility testing for all TB patients and access to rapid diagnostics for TB for all those that require it. This should also include access to free, or affordable, and quality assured TB medicines, including child-friendly medicine formulations.
- Effective implementation of the policy of mandatory notification of all TB cases (including their treatment outcome), using e-Health and m-Health approaches, and a combination of incentives as well as punitive action. In this process it is important to learn from the progress made in polio eradication related to notification and investigation of all cases of paralysis in children.
- Improvement of TB care across the country both in the public and private sector, among care providers in RNTCP, as well as those who have remained outside RNTCP. This should include strict adherence to the Indian and International Standards of TB Care which should include the prescription and use of the most appropriate diagnostics and treatment regimen. Majority of Indians approach the private sector for their health care needs and TB is no exception. As new diagnostics become available and new treatment regimens are likely in the future, there is an opportunity for the private health care sector to demonstrate its leadership and entrepreneurship. Health insurance, both by public and private sector, and the future plans on moving towards universal health coverage, are important opportunities to promote quality of care in TB and weed out sub-optimal care.
- Improvement in drug regulations and its implementation to improve the quality of anti-TB drugs and prevent irrational dispensing of such drugs. Implementation will require policies that will incentivise WHO prequalification and use of fixed-dose combination formulations with kits that have the entire course of medicine for individual patients.
- To promote early and enhanced TB case detection actively screen people who are at high risk, or who belong to vulnerable groups that are unlikely to access early care and in whom the impact of the disease can be catastrophic. In addition, care must be taken to make patients complete the diagnostic process and start treatment – currently too many patients either do not complete the diagnostic process, or do not start treatment after diagnosis. To achieve this it is important to change policies towards use of rapid and more accurate tests and faster algorithms that can diagnose most forms of TB in one patient visit to the healthcare facility.
- The civil society and affected communities need to get organised for greater advocacy, monitoring of care provision, and actual participation in the provision of TB diagnosis and treatment to patients. The experience of the HIV and polio responses in India successfully mobilised the civil society and TB has much to learn from these examples.
- India needs to use the full potential of the research capacity in the country to develop new diagnostics, new drugs and vaccines for TB. This will require increased commitment from both the public and private sector stakeholders engaged in research and health product development.