The government still needs to find the money to eliminate TB and kala azar

In his budget speech on Wednesday, Finance Minister Arun Jaitley announced the government’s intention to eliminate five chronic diseases that affect poor people. “Government has therefore prepared an action plan to eliminate kala azar and filariasis by 2017, leprosy by 2018 and measles by 2020,” he said. “Elimination of tuberculosis by 2025 is also targeted.”

Behind this announcement is the fact that the current and previous governments have set – and missed – several targets for the elimination of these diseases. The failure can almost entirely be attributed to poor investment in public healthcare in India, which has hovered around 1% of GDP and been among the lowest in the world.

Of the chronic diseases listed by the finance minister in his speech, tuberculosis is the most dangerous and difficult to tackle. The government plans to eliminate TB by 2025, this is, the number of notified TB cases should fall to 10 per one lakh population. In 2015, India had 217 notified cases per one lakh population.

Health experts who work with TB patients say that the budget plan is very ambitious. In August 2016, the World Health Organisation in its annual TB report revealed that India grossly underestimated its TB incidence rates. As per new calculations by the international body, India had 2.8 million new cases in 2015 compared to 1.7 million cases that India’s TB programme reported. The new estimates of deaths due to TB were double what the national programme reported at a little less than half a million deaths in 2015.

“I think anyone who understands TB will tell you that TB elimination by 2025 is an impossible goal, especially for the world’s highest TB burden nation,” said Madhukar Pai, director of the McGill Global Health Programs in Canada. “The key issue is how will India move from making rhetorical statements to serious on the ground implementation?”

The Health Ministry is now formulating a new action plan to combat TB, which can be finalised only after the allocations towards the programme are settled. International donors fund 62% of the programme currently.

“India needs to double its investment in TB prevention, early diagnosis and treatment,” said Chapal Mehra, a health activist who works on TB. “The government still doesn’t have enough capacity to meet the needs of all TB patients, a majority of whom seek care in the private sector.”

Apart from funds, the TB programme has suffered poor implementation. In 2015, the health ministry announced that the national programme would roll out the diay regimen of drugs for TB patients that is more effective than the alternate day regimen. The launch of this regiment has been delayed by more than a year now and in response to a public interest litigation, the government has now set the deadline for September 2017.

The department had also restricted the roll out of Bedaquiline, the new drug for drug-resistant tuberculosis, to only six centres in the country with a promise to scale the programme up in six months. The complaints of lack of access to this drug reached the Delhi High Court, where the government conceded to give the drug to patients who live outside the selected six cities.

“Unless we empower the affected community and make government officials accountable for the implementation of the programme, such announcements are useless,” said Blessina Kumar, Chief Operating Officer of the Global Coalition of TB Activists.

Leprosy – the already-eliminated disease

India claims to have eliminated leprosy in 2005 and yet, Arun Jaitley announced in the budget that the government has prepared an action to eliminate leprosy by 2018. Dr AK Puri, assistant director general of the National Leprosy Eradication Programme under the Ministry of Health and Family Welfare, expressed shock at the announcement. He clarified that the country has achieved leprosy elimination in 2005 by reducing the number of cases to less than one case per 10,000 population.

But according to Dr Nerges Mistry, director and trustee of the Foundation for Medical Research, India has never really achieved the elimination of leprosy. “Leprosy is not a disease which can even be eradicated either,” said Mistry who fears a resurgence of leprosy in India.

Elimination refers to the complete and permanent reduction to a very low rate of new cases of a disease through deliberate efforts. Eradication is the reduction of new cases to zero.

India identified 163 districts where leprosy is endemic and continues to infect children and adults leading to irreversible deformities requiring rehabilitation.

“There are some new reservoirs in the community driving the disease forward,” said Mistry. “The numbers appear to be creeping up.”

Dadra and Nagar Haveli has such communities where children are routinely infected with leprosy. In fact, 9% of all new leprosy cases in India between April 2014 and March 2015 were reported among children.

Public health experts are motivated by leprosy finding a mention in the union budget in the hope that is means that there will be more investment in leprosy control. “Both the government and international funding has dried [up],” said a senior government official.

Low hanging fruit

Elimination of kala azar or visceral leishmaniasis, on the other hand, seems within reach. Kala azar in india has been restricted to four states – Bihar, which has more than 90% of cases, Jharkhand, West Bengal and Uttar Pradesh. Elimination has been defined as reducing the annual incidence of kala azar to less than 1 case per 10,000 people at the sub-district level.

Although governments since Independence have tried to eliminate kala azar, thay have stumbled finding an effective drug protocol. The game-changer was the drug liposomal amphotericin B, a single dose of which cures the disease in a day and which is donated to India’s programme by the World Health Organisation.

To succeed with elimination, the national kala azar programme running in campaign mode in endemic districts has to be sustained over months and even after the WHO withdraws its funding. The kala azar programme involves international consortium of consultants called KalaCore, which is funded by The Department for International Development of the United Kingdom. The basic infrastructure and other medicines are funded by the Indian government.

The government should also look at two medical conditions that could become obstacles in the elimination plan. HIV positive people contract kala azar easily while people who suffer from post-dermal kala azar leishmaniasis, a skin manifestation of the disease, do not exhibit other symptoms but are carriers of the more dangerous form.