Ending tuberculosis in India: A political challenge & an opportunity

The year 2018 has special significance for the fight to end tuberculosis (TB). Heads of State will come together at the first-ever United Nations (UN) General Assembly High-Level Meeting (UN HLM) on TB in New York. This will be the third time the UN has called for a high-level meeting on a health issue. TB will be in the highest political spotlight for the first time in history, following on the heels of a successful Ministerial Conference on Ending TB in Moscow in November 20171.

The Ministerial Conference resulted in high-level commitments from Ministers and other leaders from 120 countries, and over 800 partners, including civil society, to end TB2. In specific terms, the Moscow Ministerial Declaration committed to ramp up action on four fronts:“ (i) move rapidly to achieve universal health coverage by strengthening health systems and improving access to people-centred TB prevention and care, ensuring no one is left behind; (ii) mobilize sufficient and sustainable financing through increased domestic and international investments to close gaps in implementation and research; (iii) advance research and development of new tools to diagnose, treat and prevent TB; and (iv) build accountability through a framework to track and review progress on ending TB, including multisectoral approaches”2.

Given the political importance of this year, the World TB Day is focussed on the theme ‘Wanted: Leaders for a TB-free world’. The call is aimed at building commitment to end TB at all levels, from the highest political level with Heads of State and ministers of health, mayors, governors, parliamentarians and community leaders to people affected with TB, civil society advocates, health workers, doctors or nurses, non-governmental organizations and other partners3. Specifically, it called for highest level participation at the UN HLM on TB.

India: Stepping forward as a leader for a TB-free world

In recent years, India has already taken several critical steps to showcase itself as a leader for a TB-free world, with impressive and ambitious policies and plans4. Notably, the mandatory notification of all people with TB in the country has contributed to a 37 per cent increase in notifications of new TB cases from 2013 to 2016 and, therefore, to a better understanding of the magnitude of the epidemic5. The Government of India's National Strategic Plan for TB Elimination 2017-2025 outlines an ambitious agenda and targets which exceed even the aspirational ones set by the World Health Organization's (WHO) End TB Strategy for the world6. Within the country, cities such as Mumbai in Maharashtra have taken leadership to combat the multidrug-resistant TB (MDR-TB) crisis, following reports in 2012 of cases of presumed total drug resistance beyond extensively drug-resistant TB (XDR-TB)7. The Mumbai Mission for TB Control, set up by the Municipal Corporation of Greater Mumbai in collaboration with partners, has been making excellent strides towards enhancing access to early TB and MDR-TB diagnosis and quality TB treatment in the public and private sectors8. Innovative pilot models of private sector engagement in Mumbai, Patna, Bihar and Mehsana, Gujarat, have demonstrated the impact on increased case notifications and improved quality of care by working with intermediary agencies, engaging large numbers of private care providers and harnessing e/m-Health solutions9.

Most recently in 2017, at the WHO Global Ministerial Conference on Ending TB, the Union Minister of Health and Family Welfare, Government of India, reaffirmed the government's commitment to scale up access to free diagnosis through rapid molecular tests also providing information on drug resistance, free treatment for all people with TB, with best-quality drugs and regimens, financial and nutritional support to patients, use of digital technologies for notification and adherence and linking with interface non-governmental agencies to strengthen private sector engagement. The government has also started active TB case finding campaigns in selected areas to enable access to patients in difficult-to-reach areas, both socially and geographically10. Furthermore, in February 2018, the Indian Union Budget announced an allocation of ₹ 600 crores (USD 90 million) towards nutritional support for TB patients. Under this scheme, ₹ 500 (USD 8) per month would be provided for TB patients to supplement their nutritional needs11. The Delhi End TB Summit was held from 13 to 17 March 2018, in New Delhi, India12, with participation at Head-of-State level, highlighting the political commitment to tackle TB in the country. Other meetings such as the Stop TB Partnership Coordinating Board were held on the side-lines.

Translating commitments into actions

Despite these impressive commitments, the path to transform India's promises into action is long, arduous and riddled with challenges. India still carries the by-far highest burden of TB and MDR-TB in the world. According to WHO's 2017 Global TB Report, nearly 2.8 million people fell ill with TB in India in 2016, which alone accounted for nearly a quarter of the world's TB burden. Around 435,000 people lost their lives to TB that same year5. MDR-TB remains a health security threat in the country, with an estimated 84,000 MDR/rifampicin-resistant TB cases5. Coupled with the burden are the challenges of a largely unregulated private sector and the underlying social determinants of disease, including poverty, undernutrition, poor living conditions and risk factors such as tobacco use, which drive the TB epidemic in the country.

That notwithstanding, rapid and sustainable gains are possible given the high level of commitment in the country. Five priorities merit focussed attention.

First, commitments made in the country need to be backed with adequate resources. According to reports, the government-allocated budget for the implementation of the National TB Strategic Plan needs to be boosted, in addition to the recently announced infusion of funds for nutritional support13. India must work towards closing gaps in financing by securing resources from both domestic and, for the time being, international sources. The Global Fund, the US Agency for International Development, WHO, the World Bank and The Union, among others, are already involved in TB care efforts in the country, and their support needs to be well coordinated and leveraged. Sustainability, however, demands that a growing economy like that of India progressively graduates from being a recipient of international aid towards a fully domestically funded priority health programme14 as is the case already in all the other BRICS (Brazil, Russia, India, China & South Africa) countries.

Second, access to new tools needs to be expanded both in the public and private sectors. Nearly a million people with TB in India miss out on care each year - they either access private sector or public sector TB services but are not diagnosed or are diagnosed but not notified, and/or lost to follow up before starting treatment15. In addition, nearly a third of the estimated MDR-TB patients in the country are not diagnosed or put on treatment5. India has outlined key steps and actions to close these gaps in its ambitious National Strategic Plan. Effective implementation of this Plan needs to be supported by the government and all stakeholders in the public and private sectors to expand access to rapid molecular tests such as Xpert MTB-RIF and line-probe assays and to scale up access to new drugs and regimens. Notably, the Government needs to increase access to the new drug bedaquiline, for those eligible and in need of the drug, beyond its conditional access programme16. This has recently been in the spotlight, with civil society advocates urging increased access to bedaquiline and the other new drug delamanid17. This also follows the switch, for drug-susceptible TB treatment, from intermittent therapy to an internationally accepted daily regimen as mandated by the Indian Supreme Court in January 201718. Newer treatments, including the shorter MDR-TB regimens and fixed-dose child-friendly combinations for children with TB, also need to be rolled out as these guarantee better care and acceptability by people affected.

Third, engagement with the private sector needs to be scaled up. Over half of the TB patients in India first seek care in the private sector19. The care provided in the private sector, while being more easily accessible, is often unregulated and can be of substandard quality20. Efforts are underway in the country to strengthen private sector engagement and improve case notification, especially through three pilot projects in Mumbai, Patna and Mehsana, but this is only the tip of the iceberg. The lessons learnt from these successful projects need to be scaled across the country to reach those missed by publicly provided, affordable care. The Global Fund is taking steps in this direction and is supporting the scale-up of these approaches starting in 2018 across 33 cities. Furthermore, getting private care providers to systematically notify cases through the NIKSHAY web notification system proposed by the Revised National TB Control Programme (RNTCP) is also a top priority as it ensures better understanding of the burden21.

Fourth, the underlying determinants of TB need to be addressed through a multisectoral response. TB is a disease of poverty. Studies show that the poorest quintile in India has over a five-fold risk of TB compared to the general population22. This situation is exacerbated with growing urbanization across the country, especially in overcrowded slums where TB prevalence is known to be higher23. Other risk factors such as smoking and comorbidities such as HIV and diabetes are associated with a high prevalence of TB in the country24. Addressing this requires a response beyond the mandate of the national TB programme, but within the health sector and beyond the Ministries of Social Welfare, Justice, Labour and Interior, for instance. While India is making positive strides in this direction with nutritional support and social protection schemes, significant opportunities remain to be fully tapped. The recognition and mapping of the social and economic determinants of the TB epidemic are the first steps to be undertaken to construct a truly multi-sectoral response to TB that can then be taken at the highest political level to ensure a comprehensive and holistic approach.

Last but not least, ending TB will not be possible without research. The formation of the ‘India TB Research Consortium (ITRC)’ initiative in 2016 by the Indian Council of Medical Research (ICMR), is a key step to bring together all major national and international stakeholders to enhance TB research and develop new tools for TB25. In early March, ICMR and its affiliates (NIRT and ITRC) were awarded the Stop TB Kochon prize for 2017 in recognition of India's contributions26. India is also a key partner in the BRICS TB Research Network launched at the WHO Global Ministerial Conference in Moscow2. However, these initiatives now require increased and sustained investments to succeed and deliver new tools from the pipeline. With the expertise present in India and through its world-level, high-reputation research institutions, India has a lot to offer to itself and to the world in terms of development and rapid operationalization of new tools and best practices based on implementation science.

Conclusion

As the world looks from Moscow to Delhi to take forward the commitments made by Ministers of Health, it is hoped that the highest Indian authorities will step forward to champion End TB efforts, setting the ball rolling to the UN HLM in New York. The UN HLM is the greatest ever political opportunity for the fight to end TB, and it requires leaders at all levels to heed the clarion call raised this World TB Day. For India, the bell is tolling already with the highest level commitment expressed. It now needs the impetus of all stakeholders from health workers, doctors, parliamentarians, civil society, community workers, affected people and media to make its ambitious targets to end TB a reality. Halting TB in its tracks in India will in turn pivot the global TB response, saving millions of lives in the years to come and contributing to ending TB by 2030.