India: Strengthening existing health systems to manage TB
An unregulated and greedy private sector and an inefficient and under- funded public sector in India generously allows its patients to choose between the devil and the deep seas. According to the National Family Health Survey-3, nearly two-thirds of all households (70% in urban and 63% in rural areas) in India generally seek health care from the private medical sector, while only one-third of households use the public medical sector. The most common reason given for not using public sector health care facilities is poor quality of the service, followed by non-availability of a facility nearby, long waiting time, and inconvenient hours of operation. This is a clear indication that India's public health delivery infrastructure fails to protect the interests of vulnerable groups.
The problem becomes more confounded when it comes to dealing with TB which, despite the much lauded DOTS programme, seems to be nobody’s baby when it comes to accessing good quality diagnosis, treatment, care and control. There is still a lot of denial and stigma around TB in our country. Poor awareness about the disease in the general public, coupled with apathetic and ill- informed healthcare services, have helped in fuelling the TB epidemic and escalating a deadlier form of the multi- drug resistant TB (MDR-TB).
While talking to CNS at the 43rd Union World Conference on Lung Health held in Kuala Lumpur, Dr Madhukar Pai, Associate Professor Department of Epidemiology & Biostatistics McGill University, suggested for a public private partnership that would engage and leverage the private health sector on a national scale in India. According to him this would go a long way in controlling the current rampant use of bad diagnostic tests and poor prescriptions in the private sector and make it more protocol driven.
Dr Pai also worries that, “Despite a government ban on the serological diagnostic test for TB, except for very few labs in the countries, the test goes on. Some labs resort to another bad test--the QuantiFERON test- which, apart from being costly, cannot separate latent TB from active TB. Unfortunately, unlike serology, it is a valid test for latent TB infection but is being grossly misused in the private sector for diagnosing active TB infection where it gives unacceptable levels of false positives—one in three cases is wrongly diagnosed as having active TB. The government should ban this test.”
While acknowledging the success of the Revised National TB Control Programme (RNTCP) of India in bringing down the death rates due to TB by providing free TB treatment, Dr Pai laments about the passive approach of RNTCP in waiting for people to come to it instead of reaching out to them. It is aiming for universal access to good quality TB care till 2017, without taking ownership of every Indian TB clinic—public or private- rather than just those in the programme.
According to Dr Pai, “the DOTS (directly observed therapy, short course) programme under RNTCP may be generating drug resistance as they are not doing drug susceptibility (DS) test on every patient at the start of the treatment. They are starting people on basic TB therapy, waiting for them to fail, and then doing the DS test, by which time a lot of airborne transmission of MDR-TB has already happened. TB is a national problem but is being tackled at the state level and some states are letting it down. This dis-functionality between central and state governments must end—more so because there is constant migration of people from one state to another and if the programme fails in one state it has a cascading effect in spreading the disease elsewhere. We are not doing active case finding. The frontline is usually not the public sector, but a whole variety of formal/ informal private sector and that is where the programme is least effective in India. There has to be some local economic model (to plug this vital gap) which connects the rural medical practitioners with the existing DOTS services by giving them some monetary incentives.”
Dr Soumya Swaminathan, Scientist at the National Institute for Research in Tuberculosis, Chennai, agrees that, “There are several shortfalls in management of TB and we are failing in controlling MDR TB. Indian standards of TB treatment and care should have a rational way of managing TB well—give some guidance to healthcare providers on how to diagnose and treat, and also inform the patients about the good treatment options available (other than the currently used DOTS) and then let them choose according to personal convenience. We know that daily dose regimen is often better and so not everybody may want to take alternate day therapy. So options should be made available to the patients. There have to be changes on both sides—community as well as at the health providers’ —as there is lack of awareness in general. There has to be more literacy on TB in doctors too.”
Dalbir Singh, a politician committed to the cause of TB, told CNS that it is high time TB gets the kind of attention it deserves. He wants the government to allocate budget for massive mass media campaigns to make people aware of this national crisis-- put huge hoardings near airports and other prominent places with eye catching slogans and messages highlighting important information on TB from a public health point of view. He also advocates the importance of building a second line cadre of trained medical assistants to manage the rural Primary Health Centres which perpetually experience a shortage of qualified doctors due to their reluctance to serve in the villages. A diploma training course of 1-2 years duration will be sufficient to equip these paramedics with the basic knowledge about dealing with patients suffering from TB and other diseases on a day to day basis. This can go a long way in strengthening the rural health service of India which, despite good government schemes like the National Rural Health Mission, is in a shambles for want of dedicated medical personnel.
We need to realize that the current DOTS strategy in India alone cannot help, especially in controlling MDR-TB. We need to be more ambitious and innovative and invest in new tools and strategies to be able to reach out to the masses in a more proactive manner to control the various deadly forms of TB.