New Delhi: Tuberculosis (TB) costs India $32 billion (Rs 2.2 lakh crore) every year, 3.5 times its 2019 health budget. India has the world’s highest TB burden and mortality, and the country is not doing enough to combat the preventable, curable disease, a new global report has warned.

An infectious air-borne bacterial disease that mostly affects the lungs but is preventable and curable, TB kills 421,000 Indians every year. That is the equivalent of passengers dying in 2,100 Boeing 737 MAX (200-seater) crashes, or more than five such crashes a day.

Indian TB deaths represent 32% of global TB mortality, and from current trends the country is not likely to meet its 2025 target of eliminating the disease, said the report, Building a tuberculosis-free world: The Lancet commission on tuberculosis published in the medical journal Lancet on March 21, 2019. The global target for eliminating TB is 2030.

On 12 indicators of its battle against TB, India is on track on two (tobacco taxation and political will), approaching its target on three (children with TB, universal health coverage service score and prevalence of undernourishment), but trailing on seven, namely drug- and multi-drug-resistant TB, national public-health financing, social-protection system, catastrophic health expenditure, anti-retroviral treatment for HIV patients and air pollution.

India needs to provide better diagnostic and treatment services, prioritise private provider engagement, provide universal access to drug susceptibility testing at the time of diagnosis and invest in active case-finding strategies to reduce its TB burden, said the commission report, which was chaired by Eric Goosby, a professor of medicine and infectious diseases expert at the University of California, San Francisco.

The Lancet TB commission involved 37 TB commissioners from 13 countries and mapped out priorities in diagnosis, treatment, prevention and advocacy efforts to end tuberculosis by 2030.

Currently, 10% of India’s TB patients die because they do not go to a doctor or go too late. It takes them an average of 4.1 months to get to a doctor and 57% of patients do not reach a “high-quality treatment provider”, where they are most likely to be diagnosed and treated, said the Lancet report.

Bridging these “care cascade gaps”--or gaps in the steps that a patient takes in order to get cured--will reduce India’s TB incidence by more than a third (38%) between 2018 and 2035. For both TB burden and deaths, the most important factor is patients visiting the private health-care sector in India, said the report.

Improving the state’s engagement with the private sector, where 80% of India’s TB patients seek early care, can save up to 8 million lives by 2045, said the report.

It would cost India an additional $290 million (Rs 1,999 crore) to “engage with” the private sector, said the report. Although that is half the current national TB budget, it is 0.9% of what India’s TB mortality costs: $32 billion.

Each dollar invested in reaching TB targets would provide a return of $16 to $82, said the report.

A quarter of India’s TB budget was spent on addressing the quality of TB care in the private sector, union health minister JP Nadda wrote in the TB commission’s report. This included free diagnosis, including rapid molecular tests, financial incentives to private providers, web- and mobile-based TB notification systems, digital technology for treatment adherence, etc.

Private-sector engagement

As we said earlier, 80% of TB patients first seek care in the private sector, where 46% get all their treatment. However, the quality of treatment in the private sector can vary.

In a sample of TB patients from Mumbai, seeking care from both the public and private sector, the average time taken to diagnose and start drug-resistant TB treatment was 87 days. The shortest time to start treatment was one month and longest around eight months. For drug-sensitive TB, when first-line TB drugs were effective, the duration ranged from 28 to 42 days, depending on the patient’s previous history of TB and treatment, IndiaSpend reported in February 2019.

Before 2009, only 1.5% of state TB spending in India was set aside to engage NGOs and private providers. The National Strategic Plan for Tuberculosis Elimination (NSP 2017-25) promised increased funding and called for a six-fold increase in “notification”--as reporting of TB patients is called--to 2 million patients per year by 2020 from the private sector, which would represent 75% of all estimated TB patients.

In 2017, 1.8 million TB cases--21% from the private sector--were notified in the national electronic system, called Nikshay. In 2018, 2.1 million TB cases were notified, an overall increase of 17%, of which 24% came from the private sector.

However, only 35% TB cases were handled correctly by the private healthcare sector in Mumbai and Patna between November 2014 and August 2015, IndiaSpend reported in October 2018.

Implementation hurdles

Despite the government’s commitments and claims, uneven implementation has slowed progress.

For example, even though the private sector treated about 2.2 million patients, according to this 2016 study in The Lancet, only about 541,000 were notified, as per Nikshay records in 2019. That means 76% of TB patients from the private sector were not reported to the government.

India is still in the process of implementing a universal drug-susceptibility test (DST), which detects drug resistance on all TB samples, as it has committed to under the NSP 2017-2025. Only 257 of India’s 712 districts offer the universal DST test, according to the India TB Report, 2018, and only about 32% of notified TB patients underwent universal DSTs, IndiaSpend reported in January 2019.

These testing failures could explain why no more than 28% of India’s 135,000 estimated drug-resistant TB patients were diagnosed and only 26% treated in 2017, according to the Global Tuberculosis Report 2018.

Despite 2018 WHO guidelines that make bedaquiline--a new drug for TB--part of the core regimen for 135,000 drug-resistant TB patients in India, only 3,000 received the drug till January 2019, we reported.

(Yadavar is a principal correspondent with IndiaSpend.)

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