TB control: challenges in engagement

Published in The Hindu on September 20, 2012

Engaging the private practitioners in the fight against TB is easier said than done. For instance, there is a dichotomy in the way the public and private sector treat a TB patient. Private practitioners prefer to treat their patients with a daily fixed dose combination therapy while the RNTCP is built on an intermittent (thrice a week) treatment.

“India is the only country in the world that gives intermittent treatment,” says Dr Nalini Krishnan, Director of Chennai-based REACH. “It’s because it is easy to administer by the DOTS providers and has less toxicity.” For the doctors from the private sector, compliance becomes an issue when it is intermittent. “Hence they prefer daily treatment,” she says. The World Health Organisation not only endorses daily therapy with fixed dose combination, but is also pressuring India to convert to daily treatment. Still, the government and private practitioners are not on the same page. “The failure of the programme to acknowledge the acceptability of WHO endorsed daily fixed dose combination therapy administered in the private sector undermines its credibility and creates conflict with private providers,” the draft points out. “The programme so far has remained rigid in its recognition of other internationally accepted protocols for diagnosis and treatment of TB.”

“Clinical trials have shown that thrice a week regimen and daily regimen are same in terms of efficacy (cure rate). So efficacy wise the two regimens are same, but convenience becomes a factor with RNTCP’s DOT,” says Dr. Soumya Swaminathan, Director of the Chennai-based National Institute for Research in Tuberculosis (earlier called the Tuberculosis Research Centre). “There is nothing wrong in daily regimen and doctors are justified in prescribing daily regimen.”

Both the draft Joint Monitoring Mission and the draft National Strategy Plan for Tuberculosis Control 2012-2017 have recommended developing Indian standards of TB care that is applicable to all sectors (public and private). “The programme needs to take steps to develop Indian Standards of TB care which recognize the evidence based rational treatment for TB even outside the programmes as well as gather evidence and examine the necessity of new treatment regimens for TB,” the Strategy Plan underlines. “There should be a menu of treatments so doctors can choose any one. This will give doctors the flexibility,” Dr. Swaminathan says. “But government insists on interrupted regimen. It is not flexible as of now.”

While the RNTCP’s regimen is for six months, private practitioners want the therapy to be continued for nine months in the case of extra-pulmonary TB. Unlike the HIV programme, where NGOs are empowered to diagnose and treat patients according to the government guidelines, RNTCP is yet to decentralise DOTS programme. “RNTCP hesitates to include other stakeholders for providing DOT,” Dr. Krishnan says. This is highlighted by the fact that the draft clearly brings out the unwillingness of the government to involve other stakeholders. “The [RNTCP] programme needs to examine the process adopted by the other programmes and examine the possibilities of replicating them,” it highlights.