What does elimination of TB in India mean?
World Health Organisation’s (WHO) End TB Strategy has set the target for TB elimination globally at 2035.1 But India has set its own target for TB elimination a decade earlier that is at 2025. With 17% of the world population, India contributes to a quarter of TB cases of the world; the incidence of TB being 204 per lakh population with 31/lakh dying due to TB every year.2 To eliminate TB means to reduce the incidence to less than 10 cases per 100,000 population.1 The reduction from 204 to less than 10 is an uphill task for the Revised National Tuberculosis Control Programme (RNTCP). Though RNTCP still retains some vertical structure, it is mostly integrated with the other programmes in the health system under the National Health Mission. Therefore the success of the programme depends to a great extent on the health infrastructure and manpower available in the states. To be more specific, elimination of TB will be determined by the performance of the states and the country in the six components of the health system.
Plan for TB elimination
World Health Organisation has proposed a framework for the health system with six building blocks. These are (i) service delivery, (ii) health workforce, (iii) health information systems, (iv) access to essential medicines, (v) financing, and (vi) leadership/governance.3 The framework suggests that the access, coverage, quality and safety of health services depend on these six building blocks thereby ensuring the health outcomes of all the programmes. The same is equally applicable to the TB control measures targeting elimination. The recently launched National Strategic Plan (NSP) for 2017-25 has proposed ambitious plans towards elimination of TB in India through a four pronged approach - Detect, Treat, Prevent and Build.4
Detect - For detecting all drug-sensitive (DS-TB) and drug-resistant TB (DR-TB), the steps proposed are scaling up of highly sensitive diagnostics and algorithms, universal testing of drug-resistant TB and systematic screening of high-risk population. All this is possible through scale-up of private provider engagement.
Treat - To Initiate and sustain all patients on appropriate anti-TB treatment, what is needed as proposed in NSP is provide free treatment to all, monitor treatment adherence and prevent loss of TB cases in the cascade of care and as a result, the catastrophic expenditure can be avoided.
Prevent - To prevent TB in susceptible populations, measures suggested are scale-up of air-borne infection control measures in health care facilities and treatment of latent TB infection (LTBI) and overall addressing social determinants of health.
Build - To build capacity among human resources and enabling policies, the recommendations are high level political commitment, reforms in the programme in aspects of management, surveillance and harmonisation of partners’ activities.
Success of this plan is important as the global TB community is now watching India’s performance in TB control. Therefore there is a need to assess whether the present health system of the country and the states individually are adequately equipped to implement the recommended strategies for elimination of TB in India. The introspection at this stage is essential to evaluate whether the target is achievable and what is required outside the ambit of TB programme to make it achievable. For each of the strategic pillars suggested in NSP, let us review the building blocks of the health system that will be involved in its successful implementation.
Health system wise approach to TB elimination
Many of the strategies in NSP are being adopted in phases in the RNTCP. Effective implementation of the strategies however depends on the existing health system of the country. First of the pillars - Detection of all cases of TB is presently being attempted through Active Case Finding in risk groups like HIV positive people and diabetics in collaboration with national programs NACP (National AIDS Control Programme) and NPCDCS (National Programme for Control of Cancer, Diabetes, Cardiovascular diseases and Stroke). Bidirectional screening is being done to detect more cases. Launch of universal DST (Drug Sensitivity Testing) for all TB patients will increase the detection of DR-TB. However, successful implementation of these strategies and thereby detection of all cases of TB can be achieved through good leadership/governance by financing purchase and supply of high sensitivity diagnostic tools as CBNAAT at the most peripheral health institutions like Primary Health Centres (PHC) which covers a population of roughly 30,000 covering nearly 30 villages in rural India. This appears utopian in the present day because the steps and processes that will lead to fulfilment of this idea are still lacking. Health information system in TB is still incomplete with inadequate reporting from the huge private sector in India. At the grass-roots level, the health workforce is still insufficient to handle the additional burden of TB. Public health infrastructure is substandard in many parts of the country. Therefore even though the access to drugs has been ensured by RNTCP, there is a long way to go for service delivery to improve for detection of all cases of TB.
The next pillar - Treat aims at providing appropriate and free treatment for all cases of TB. A lot is happening in this area with the academicians and programme managers joining hands in conducting core laboratory, operational and implementational research to bring the advantages of science to the people. In this process research has helped in reducing the duration of treatment for DR-TB, development of Information Communication and technology (ICT) tools for adherence monitoring and nutritional support in the form of DBT (Direct Benefit Transfer) for spatients undergoing treatment for TB. But the challenge in treatment of all cases lies in detection of the cases and linking up with RNTCP to ensure initiation of appropriate treatment and access to other benefits which depends largely on public health system of the country and also political will and governance to regulate the private sector.
For the third pillar - Prevention of TB, the long term solution of improving on the social determinants of health is beyond the purview of the health system. But control of air-borne infection in hospitals and treatment of Latent TB Infection (LTBI) require leadership, governance and financing. To modify all healthcare facilities to adhere to the infection control norms, huge infrastructural development will be required. Health workforce will be required to identify all LTBI cases. India is considering WHO recommendation of chemoprophylaxis of all household contacts irrespective of age. But to make this is fruitful, identification of all cases is required in the first place, which remains the most difficult task and providing financial arrangement for procuring and sustaining the availability of drugs.
Fourth pillar - Build stresses the need for a separate cadre of health workforce for surveillance and changes in the management and institutional arrangement of RNTCP. NIKSHAY, a portal in place for TB case notification in RNTCP helps to monitor and track services and status related to screening, diagnosis, treatment and follow-up of Tuberculosis cases. But the implementation is far from complete because of lack of involvement of the private sector. A timely and appropriate recommendation for choice of interventions based on local epidemiological situations has been given in NSP considering that the TB scenario differs in different regions, states and cities in the country. But this requires highly motivated, competent and trained staff in the programme which otherwise will lead to chaos and loss of direction. To build up such policies, health workforce and programme is challenging.
This is a gross overview of the health system support required for TB elimination in India. The managers and policy makers are continuously reviewing the situation. But to make any firm strides in TB control more needs to be done otherwise the targets will remain un-achievable as many other health indicators in the country.