India’s Ambitious TB Eradication Target : Realistic Goal or Elusive Dream?

Tanu Paliwal

Abstract 

With two deaths occurring every three minutes, India continues to top the globe in TB prevalence. Tuberculosis, or TB, is an infectious bacterial disease caused by Mycobacterium tuberculosis that mostly affects the lungs. It spreads from person to person via droplets from the throat and lungs of people with active respiratory illness.

It has been 60 years since efforts for treatment, prevention, and cure began in the country, with the most recent attempt being the Ministry of Health and Family Welfare’s National Strategic Plan 2020-2025 for TB Elimination, established with the intention of meeting SDG End TB targets by 2025, five years before the global target of 2030. Its primary goal is to reduce the burden of TB, improve patient outcomes, and ultimately eliminate the disease.

Background 

In 1992, it was projected that TB caused 7-8 million new infections and 2-3 million deaths worldwide each year. The World Health Assembly established global targets of 85% cure rates and 70% case detection among infectious infections in 1991. In 1993, WHO designated tuberculosis (TB) a worldwide emergency and established the five-element DOTS plan, which entailed closely observing patients taking their medication to ensure adherence, enhance treatment outcomes, and avoid resistance.Countries adopted DOTS in large numbers between 1994 and 1995.

By  2000, 148 nations had adopted the new DOTS policy, including all 22 highest burden countries (HBC) responsible for 80% of cases worldwide. Nevertheless, progress in case detection remained slow due to incomplete geographical coverage or the need to widen detection and notification capacity with innovative schemes.

 The fundamental barriers to TB control became increasingly apparent, and a global Stop TB Partnership was finally formed to overcome such barriers. A Global DOTS Expansion Plan identified the gaps for meeting the global targets in 2005. In 2002, the major focus remained the rapid expansion of DOTS, using a variety of new ways to boost case identification and notification while maintaining high cure rates. Collaboration with the commercial sector and communities, as well as the strengthening of primary care services, were required.

In 1962, the Government of India launched the “National TB Programme” as a District TB Centre model that included BCG vaccination and TB treatment to combat tuberculosis. Since then, the tuberculosis control programme has progressed tremendously and undergone major changes. In 1998, the Indian Revised National Tuberculosis Control Programme began large-scale statewide implementation of the World Health Organization’s global tuberculosis control strategy (DOTS), and it has since grown quickly. By April 2006, nationwide coverage was expected. However, over half of tuberculosis patients in India seek treatment from the private healthcare sector, where diagnosis, treatment, and reporting practices frequently do not follow national or international tuberculosis standards.

The Ministry of Health and Family Welfare produced a “National Strategic Plan” for Tuberculosis Elimination (2017-25), outlining the ambitious and innovative efforts required to eliminate tuberculosis in India by 2025, five years ahead of the worldwide target. According to this plan, India should report no more than 44 new TB cases or 65 total cases per lakh population by 2025. In 2021, the estimated TB incidence was 210 per lakh people.By 2020, it was evident that the NSP-2017-25 would be unable to meet these objectives, thus a new NSP India 2020-2025 was formed with the intention of expediting national response and giving a new set of targets.

Goals 

NSP India 2020–2025 identifies a number of goals  to be carried out for the elimination of TB from India. The recommended actions include:

  1. Implement widespread and accessible screening programs to detect TB cases at an early stage;
  2.  Provide top priority reinforcements to the existing workforce;
  3.  Scale up private sector engagement;
  4. Build a network of informed and empowered communities by educating the public, dispelling myths and stigma associated with TB, and encouraging community participation in prevention and control efforts;
  5.  Investment in TB surveillance staff and systems for accurate, complete and timely information;
  6.  Deployment of new precision diagnostic tools;
  7.  Provide special attention and targeted interventions in states with a higher prevalence of TB to address the specific challenges in these regions;
  8.  Develop targeted strategies to reach and support vulnerable populations, such as those co-infected with HIV or living in impoverished conditions, recognizing the unique challenges they face;
  9. Integrate nutritional support programs into TB care to improve patient outcomes, recognizing the link between malnutrition and TB.

Performance 

  1. Introduction of Ni-kshay: A case-based web-based surveillance system is developed to provide real-time data entry and to improve the quality of information related to the burden of TB in terms of incidence and mortality.
  2. TB Mukt Gram Panchayat Abhiyaan: A campaign that aims to involve local communities at the Gram Panchayat (village council) level in the mission to make specific geographical areas free from tuberculosis.It involves mobilizing communities and local leaders, the goal is to create an environment conducive to eliminating TB in specific geographic regions.
  3.  Ni-kshay Mitra Initiative: It involves individuals, often volunteers or community members, who provide additional support to those on TB treatment. They support by adopting health facilities, blocks/urban wards/districts/states for accelerating response against TB to complement government efforts. It is to ensure additional diagnostic, nutritional, and vocational support to those on TB treatment.
  4. India’s annual TB Report: The report is published by the Central TB Division, Ministry of Health and Family Welfare, Government of India every year. It provides a comprehensive overview of the tuberculosis (TB) situation in India, summarizing key data, trends, and initiatives related to TB control.
  5. Ni-kshay Poshan Yojana: Undernutrition has been identified as one of the key drivers of the epidemic (35% population attributable factor).This initiative  provides a monthly nutritional cash support of ₹500/- per month to TB patients. 


Emerging Issues in TB Eradication from India

  1. Growing gap between the allocation of funds and the minimum investment required to reach the goals of the Plan.
  2. The existing TB surveillance system lacks the capacity to count the large pool of privately diagnosed and treated TB cases, and what is not measured is unlikely to be improved.
  3. The private sector is massive, heterogeneous, and growing with more than half the TB patients in the country being cared for in this sector. In spite of mandatory notification, many patients are not notified,making it difficult to calculate the actual burden of disease.
  4. Within the public sector, there is heavy dependence on an insensitive diagnostic test, microscopy of sputum, which, in addition, cannot diagnose drug resistance. 
  5. The enormous diversity between states, and even districts, in terms of the population, terrain, level of development, health systems, and epidemiologic variety pose problems for a uniform centralized approach to TB control.
  6. Lack of awareness in the community on TB diagnostic facilities in the programme (patient pathway- largely multiple consultations leading to delays)
  7.  New diagnostic algorithm will require additional resources for molecular tests.
  8.  Lack of collaboration between private and public sectors.Public-private mix has been defined by WHO as strategies that link all healthcare entities within the private and public sectors (including health providers in other governmental ministries) to national tuberculosis programmes.
  9. Increasing number of drug-resistant TB cases in India. This type of TB is much harder to treat and requires more expensive, specialised drugs and a longer duration of treatment. Lack of research and an inability to implement measures to cap the treatment and drug costs are aiding the spread of the epidemic. 

Way Forward 

The challenge of tuberculosis requires a multi-sectoral response to address the social determinants like nutritional support, living and working conditions, and easy access to diagnostic and treatment services. Although the efforts of the GoI are yielding significant results, the community and the institutions in the society can play a critical role in filling gaps and addressing social determinants, thereby contributing to the national goal.

More support is required from co-operative societies, corporates, elected representatives, individuals, institutions, non-governmental organizations, political parties and partners who can support by adopting health facilities (for individual donor), blocks/urban wards/districts/ states for accelerating response against TB to complement government efforts, as per the district-specific requirements in coordination with the district administration.

Apart from the current support provided to the TB patient like free diagnostics, free drugs and Nikshay Poshan Yojana, there is also a need for augmenting community involvement in meeting India’s commitment to end TB by 2025 and leveraging Corporate Social Responsibility (CSR) activities.

References

Dr V Ravi, Multi-drug resistant Tuberculosis – A major threat to global health security, March 24, 2023

https://timesofindia.indiatimes.com/blogs/voices/multi-drug-resistant-tuberculosis-a-major-threat-to-global-health-security/

Press Information Bureau, August 17,2023

https://pib.gov.in/PressReleseDetail.aspx?PRID=1949971

Press Information Bureau, March 24, 2023

https://static.pib.gov.in/WriteReadData/specificdocs/documents/2023/mar/doc2023324176101.pdf

Central Tuberculosis Division,MoHFW, March,2023

https://tbcindia.gov.in/index1.php?lang=1&level=1&sublinkid=4160&lid=2807

World Health Organisation,South-East Asia,India

https://www.who.int/india/health-topics/tuberculosis

Anonna Dutt,World TB Day 2023: How India plans to achieve its target of eliminating tuberculosis by 2025, March 24, 2023

https://indianexpress.com/article/explained/explained-health/world-tb-day-how-india-plans-to-achieve-its-target-of-eliminating-tb-by-2025-8515410/

National Strategic Plan for Tuberculosis:2017-25 Elimination By 2025,MoHFW, March,2017

https://tbcindia.gov.in/WriteReadData/National%20Strategic%20Plan%202017-25.pdf

President’s Secretariat,PIB, September 9,2022

https://pib.gov.in/PressReleaseIframePage.aspx?PRID=1858024

Disclaimer : All views expressed in the article belong solely to the author and not necessarily to the organisation.

Acknowledgement : The author would like to thank Nayana Sharma, Reet Lath and Rahul Soni for their kind comments and suggestions to improve the article.

Tanu Paliwal is an IMPRI research intern

Read more by the author: National One Health Mission: India’s Readiness for Upcoming Pandemics.