Chronically low investments have made our public health systems fragile and overburdened, such that they have become incapable of reversing India’s TB crisis by themselves.
Credit: centralasian/Flickr, CC BY 2.0
Tuberculosis (TB) is one of the biggest scourges of modern India as well as among its toughest public health problems. According to the WHO and India’s Ministry of Health and Family Welfare (MOHFW) both, about 2.8 million people contract TB in India every year. About 87,000 of them are co-infected with HIV.
Not only does the disease affect the health, employment and economic condition of the patients, it also kills almost 480,000 people per year (about 1,400 per day). In recent years, India has also become home to the largest numbers of people suffering from multi-drug-resistant (MDR) TB: about 147,000 people have the MDR strain.
India’s TB control efforts have thus far been guided by the National Strategic Plan 2012-2017. An evaluation in 2015 observed that the plan did not achieve the projected increase in case detection, possibly because it did not have the requisite funds to do so. Although almost half of all TB patients sought care from the private sector, the programme failed to engage meaningfully with the private sector. Increasingly, with the emergence of MDR strains, there has also been a growing need for scaling up facilities for drug sensitivity and testing.
Many studies and field experiences have also revealed that patients suffering from TB also require intensive social and economic support to ensure full treatment and recovery. Our own experience of working in rural, high-migration communities in southern Rajasthan (source) and in urban high migration areas in Ahmedabad (destination) has revealed the problems these population face in seeking care and completing treatment. In the city, migrants live in crowded areas, inhale dust and silica and consume foods deficient in micronutrients, proteins and energy – all leading to malnutrition. Thus, they become predisposed to contracting TB.
The migrants also work long hours without break and often do not have a weekly holiday. Their care-seeking is hindered by their being unfamiliar with health systems in the city and because their family and other sources of social support are absent. So they mostly end up seeking treatment from private providers, spending a lot of money and yet continuing to harbour the TB bacteria in their bodies.
They also often carry on with their work till they are much sicker and no longer able to continue. At this stage, they return to their native villages and seek care, once again, from a traditional healer or a private provider; the latter is typically unqualified since the economics of poor villages do not favour the growth of a formal private sector. Public facilities are not commonly sought because they are not nearby, their providers are unfriendly and their quality of service is (widely perceived to be) poor. By this time, treatment expenses have also grown and savings have dwindled, which forces the labourers to quit treatment regimes midway or to borrow (more) money.
At some point, the MOHFW acknowledged the gravity of the situation as well as key factors affecting the disease’s control, and developed an ambitious strategic plan for an eight-year period, from 2017 to 2022, along with its partners. The plan aimed to drastically cut down the emergence of new cases by five times, from 212 to 47 per 100,000 people, and deaths by ten times, from 32 to three per 100,000 people.
The plan is ambitious but not unrealistic. It clearly identifies the strengths, weaknesses, opportunities and threats of the current programme and, based on this assessment, outlines key strategies. The estimated cost for undertaking the revised plan for the first three years is Rs 16,649 crores (about Rs 5,500 crores per annum) from 2017-18 to 2019-2020. This money will be spent on expanding care to the private sector, scaling up laboratory services including for drug resistance testing, offering social and economic support to patients of TB and, finally, strengthening health-delivery and management systems. However, the plan document does caution that the shortage of funds is a significant threat to its success.
Stephen Lewis, an ex-UN envoy for HIV-AIDS and co-director of AIDS-free World, an international NGO, visited India in 2017 for a TB fact-finding mission facilitated by the US Centres for Disease Control and Prevention. As a former UN envoy, Lewis comes with a long and significant experience of assessing, observing and analysing disease control systems around the world. He visited and interacted with everyone from top bureaucrats to TB patients and survivors.
In a scathing report published later last year, he called the goal of the revised plan – to eliminate TB in India by 2025 – an “aspirational mythology”. Lewis expressed concern and dismay at the lack of a sense of urgency he had witnessed in different quarters. Among other things, he commented that India’s public expenditure on healthcare, 1% of its GDP, was a “gross rebuke” to the health of the nation. Indeed, such chronically low investments have made our public health systems fragile and overburdened, such that they have become incapable of reversing the TB crisis by themselves.
So, no further example to illustrate India’s abject failure in controlling the rise and spread of TB among its citizens is necessary beyond budgetary allocations for the control of communicable diseases (which includes TB). Despite the huge and uncontrolled problem of TB in India, the presence of a well-designed and costed plan for controlling it, vocal political commitment and an acknowledgment that more money is needed for it to bear fruit, the 2018 Union budget suggests that the finance ministry simply turned a deaf year.
Of the total estimated requirement of Rs 5,500 crore per year for implementing the TB Strategic Plan alone, the budget allocated only Rs 1,928 crore for controlling all communicable diseases. It is not clear whether the Rs 600 crore allocated for providing Rs 500 per month to TB patients for nutritional support are included here or are separate. But even if that is a separate allocation, the money is not enough to meet the nutritional requirements of TB patients, and also distracts from the severe resource crunch that this budget will leave the national TB control programme with. The oversight will potentially contribute to millions of preventable deaths. The government should urgently reverse the situation by allocating additional resources for TB control during this financial year.
Pavitra Mohan is secretary and Sanjana Brahmawar is director, Basic HealthCare Services.