New Delhi: India is going to miss the 2025 target for tuberculosis elimination that the Narendra Modi government had set for itself, the Global Tuberculosis Report 2024 report has revealed. The World Health Organisation, which has prepared this report, has set a global deadline of 2035.
Like all other countries, India has made improvements on many elimination indicators. But a close analysis of numbers presented in the report clearly indicates that India has missed the goals set for two out of three interim milestones for 2025 and is far from keeping to both the Indian government’s own elimination deadline of 2025, as well as the WHO’s deadline of 2035.
Although this trend is visible for a majority of the countries around the world, India is the only country which had set an ambitious deadline of 2025. Prime Minister Narendra Modi announced this target at a public rally in Varanasi in 2023.
There are three major milestones necessary to be achieved for the ‘TB End Strategy’ which the WHO has set for all countries. India’s parameters for elimination by its own deadline are also the same. The WHO has set final targets for 2035 and two sets of interim targets to be achieved till 2020 and 2025.
They include a reduction in TB deaths by 95% from deaths in 2015. Similarly, the incidence of TB has to go down by 90% as compared to the 2015 rate. The number of TB patients who incur ‘catastrophic expenditure’ on TB treatment has to brought down to zero.
India’s performance is as follows.
India’s burden
Historically, India has always had the highest burden of TB cases around the world. As per the current report, India accounts for 26% of all TB cases in the world. The countries that follow India are Indonesia (10%), China (6.8%), the Philippines (6.8%) and Pakistan (6.3%).
At present, the estimated number of TB cases in India are 20 lakh – the highest in the world.
The current incidence rate of TB in India is 195 cases per 1 lakh people, as against the WHO’s target of 55 cases per 1 lakh people by 2025, the interim target.
The world was already not on track to achieve these targets but the COVID-19 pandemic made the task much more difficult as services for TB control were badly hit during that period. This led to some sort of a reversal of progress made in the previous years.
However, no country other than India has fixed the target of achieving TB elimination by 2025. It was not clear whether the Indian government took the reversals into account before deciding on an ambitious target year.
Source: Global Tuberculosis Report 2024.
The reduction in TB deaths is another important indicator. India reduced deaths by 24% in 2023 as compared to the number of deaths in 2015. It failed to achieve the target set even for 2020 – which is a 35% reduction. Going by the current trajectory, it is more than likely that India will miss the interim and the final targets.
Source: Global Tuberculosis Report 2024.
Though the world as a whole also missed the death reduction target for 2020, at least 43 countries reached or surpassed this particular milestone set for the given year. India accounts for the highest number of TB deaths per year.
The third indicator is the amount of money spent on TB treatment. A household usually incurs significant expenditure on TB treatment – a spend of more than 20% of a household’s annual income for the purpose is considered a ‘catastrophic expenditure’. These include direct costs like treatment and diagnoses or indirect costs like transport and lodging, as per WHO.
The loss of income on the part of the patient and family members who accompany the patient to a TB treatment centre for treatment purposes also come under indirect cost.
“These pose barriers that can greatly affect their ability to access diagnosis and treatment, and to complete treatment successfully,” the report states.
In India, out of all households which have TB patients, at least 20% of them face catastrophic expenditure – a significant section if absolute numbers are considered.
The global average of such households in 49%. The TB elimination target had envisaged that the proportion of such families should have been reduced to zero by 2020 itself.
Governments usually get international funding in addition to incurring domestic expenditure to fight TB.
The domestic expenditure of the Indian government has been continuously rising since 2020. However, it is yet to reach the pre-pandemic levels of 2019. In other words, the domestic expenditure in 2023 was US $ 253 million, while in 2019, it was more than US $345 million.
Source: Global Tuberculosis Report 2024.
One of the major challenges with TB elimination is the number of TB cases that are missed. A significant proportion of TB patients remain either undiagnosed or unreported, officially. Cases which fall through the cracks severely affect the fight against TB because the infection spreads from one person to another. An untreated person can pass on her infection to another, in that case, thus increasing the TB burden further.
The measure to understand what proportion of cases are being missed is to look at the notification rate of patients. The higher the notification rate, the better it is. During the COVID-19 years, the notification rates of a majority of countries, except for some in the African region, went south. The current report says notifications in most of the 30 high TB-burden countries has recovered to pre-COVID levels or beyond.
India and Indonesia contributed the highest numbers in this recovery in 2022 and 2023, accounting for 45% of the total increase in reporting in the past three years.
Despite this achievement, there is a gap of around five lakh between reported and unreported cases in India, stymying the overall progress, the report says. It is the biggest gap registered by any country.
A similar and significant gap exists in the case of drug-resistant TB patients.
Patients who become resistant to the first line of drugs are known as multi-drug resistant (MDR) TB patients. Those who become resistant to the second line of treatment as well, are known as extensively drug resistant (XDR) TB patients.
Ten countries accounted for about 75% of the global gap. India leads this category too, followed by the Philippines, Indonesia, China and Pakistan.
The resistance to drugs usually happens when a patient stops taking drugs. This may happen either due to their own volition or a shortage of drugs.
India has been battling a shortage of drugs for MDR-TB, intermittently, in the last two years. Although the Indian government has consistently denied claims of any shortage.
Replying to The Wire‘s query in a virtual presser on October 29, WHO’s TB division head Tereza Kasaeva said the WHO is aware of the Indian problem of MDR TB drug shortage.
“Our regional representatives were closely following the situation and tried to support the Indian government. These are purely managerial issues. We hope it will be effectively mitigated and avoided in future because its extremely sensitive,” she added.
The problem still continues to exist. “At least two states – UP and Bihar are still facing a shortage of MDR TB drugs,” Ganesh Acharya, a TB survivor and treatment advocate told The Wire.
To attest to the gap between the actual number of TB cases and the ones which get reported, the governments, including India’s, need to up their game with diagnostic tools.
For the detection of non-drug resistant TB, the WHO has been recommending since 2011 the adoption of rapid molecular tests as against the traditional culture and microscopy methods. The latter not only take more time in giving final results, but are also less accurate than rapid tests.
However, in India, only 20-30% of all TB cases are diagnosed through molecular tests, the report says.
Since TB can be transmitted from one person to another, the WHO recommends giving preventive treatment to the families of patients who have tested positive for TB. India has covered only 31% of such contacts of TB patients.
Source: Global Tuberculosis Report 2024.
The WHO also recommends addressing the causes of TB. In the case of India, the elephant in the room is undernutrition. Undernutrition weakens the immune system of the body thus making healthy patients, especially contacts, vulnerable to TB infections. Those suffering from TB also need a healthy diet to improve treatment outcomes.