India makes new plans to end TB but no one knows how they will work

For the first time, India has decided to take action to end tuberculosis in the country. A week after after the Global Tuberculosis Report 2016 was released by World Health Organisation on October 12, the central TB department along with the WHO, non-profit organisations and experts from all over the country gathered to discuss the course of action to end the disease. Till now India has only strategised about how to control TB.

One of the targets of the Sustainable Development Goals set by the United Nations is to reduce the incidence of TB. The WHO wants the world to reduce 95% of incidence by 2035 and 95% of the deaths from the disease by 2050. But India is being more ambitious.

“The Prime Minister’s office could like to accelerate the progress,” said Dr Sowmya Swaminathan, head of Indian Council of Medical Research. “The government has given us the challenge to not end by 2030, but by 2025.”

This might be difficult considering that the WHO report recalculated the figures to show that India had a 2.8 million new cases in 2015, as compared to 1.7 million cases that India’s TB programme was showing in its annual report. The updated estimate of tuberculosis deaths excluding deaths of HIV-positive people was 4,78,000 in 2015 and 483,000 in 2014, according to the WHO report – that is double of what was estimated earlier.

A study published in PLOS Medicine in October showed that only 39% of the 2.7 million patients treated for TB in government facilities in India completed treatment and survived a year without experiencing a relapse. For patients with multi-drug resistant TB, where patients are resistant to the first line of drugs, 6,413 or 11% of 61,000 patients who reached government TB clinics completed treatment and survived for a year without relapse.

“A key conclusion is that Revised National Tuberculosis Control Programme will need to find more resources and address the leaks in the care cascade in the public sector,” said Dr Madhukar Pai, associate director at the McGill International TB Centre in Canada and one of the authors of the study.

Apathetic officials, inefficient systems

So far, health officials have mostly been apathetic to TB and hostile to criticism.

At the National Strategic Plan meeting on October 19 in Delhi, this reporter was asked to leave on the grounds that her presence made the health ministry officials at the event “vulnerable”. They said that it would only be appropriate for the media to report on the TB plan of action after plans were finalised.

On October 28, at the 47th Union World conference on Lung Health at Liverpool in the United Kingdom, global health activists protested the government’s inertia in implementing TB policies. India’s director general of health services Dr Jagdish Prasad called the protestors “unstable”.

The lack of political will of countries with high TB burdens, particularly India, spurred the WHO into calling for the first United Nations General Assembly on TB.

Old plans waiting to be implemented

One of the major demands of patient groups having the daily regime – a treatment plan which patients normally stick to longer and one that was supposed to be implemented last year.

Currently, the government runs the Directly Observed Treatment Short or DOTS course for TB treatment where the patients would take seven or eight anti-TB medicines on alternate days of the week. Each dose is handed out by a healthcare provider at a clinic. The practice makes it cumbersome for patients to follow and when they drop out often leads to drug resistance.

Patients with both HIV and TB are even less inclined to adhere to this programme. They have a better chance with the method used worldwide of a fixed dose combination treatment which involves taking three or four pills every day.

After the Global TB Report was released, Dr Sunil Khaparde, deputy director general of the TB control programme, said that the daily regime would be rolled out in November for HIV positive patients and that the necessary drugs had already arrived. However, the programme has showed no signs of starting so far. The next plan was to roll out daily regime for all TB patients in five states- Madhya Pradesh, Karnataka, Sikkim, Kerala, and Himachal Pradesh.

The government is still to roll out the drugs. “We have to just fix a data and roll the drugs out,” said Kharpade. “But it will happen this year. Pucca – for sure”

Same old policies

The Delhi meeting in October discussed many policies that had been brought up earlier in the National Strategic Planning 2012-’17. This time too, the government discussed active case finding, which allows the health system to look for a patient rather than depending on patient walk ins at healthcare centres. The TB department has proposed to have an active case detection drive “in campaign mode” between January 1 and January 15, said Khaparde.

Khaparde said that they wanted to conduct active case finding in high-risk areas such as tribal populations, people who live in congested areas, and migrants. The department is yet to map these areas.

Another ambitious plan involves public-private partnership. Since 2013, the government along with some non-profit organisations like PATH has been running successful public-private partnerships in Mumbai, Patna and Mehsana.

The government wants to scale up these models to the national level. The question is whether they have the resources.

The other plans include having more sensitive TB tests in the country including cartridge-based nucleic acid amplification test or CBNAAT machine and Drug Susceptibility Test, both of which can detect drug sensitive TB.

Another major component includes nutrition. Undernutrition is one of the leading causes of TB, and government wants to give social support and nutrition to TB patients. Currently, only states such as Chhattisgarh, and Kerala have implemented this at a small scale.

So far, budgetary allocations have been dismal. Health departments will have to seek money from international funding agencies such as World Bank. Officials are also relying on the fact that the Prime Minister Narendra Modi has assured them of adequate allocations for the next plans.

Government’s new plans

• Roll out daily drug regimen in five states and for all HIV positive persons by this year this year
• Active case finding in high risk areas
• Scaling up public-private partnerships
• Providing nutrition and social security support
• Grievance redressal systems possibly involving a helpline
• Results of country-wide multi-drug resistant tuberculosis prevalence study by the 2016-end
• New country-wide TB prevalence study by early next year
• New body called India TB Research and Development Corporation to conduct practice-based research studies for better diagnostics, a vaccine protocols for prophylactic treatment, and regimes for multi-drug resistant TB.

Activists sceptical

Despite the announcement of new plans, activists associated with TB are cynical. “I would personally take this plan with a pinch of salt,” said Dr Mohammed Shamin, a consultant with the WHO.

Activists feel that the plans look good on paper but it is not clear how they will be implemented as they need large sums of money and unwavering commitment from the government.

“There is no urgency in the programme yet,” said Blessina Kumar, chairperson of the Global Coalition of TB Activists. “The report puts a lot of onus on the programme to address it in a real war footing. They are not doing that.”