India’s TB control policy for 2012-2017 may mark a paradigm shift in the way TB is detected and treated if all the five major objectives listed in the draft version of the National Strategic Plan for Tuberculosis Control 2012-2017 are implemented in full earnest during the next five years. The National Strategic Plan sets the roadmap for RNTCP (Revised National TB Control Programme).
The most radical departure listed in the draft is to “extend RNTCP services to patients diagnosed and treated in the private sector.”
The other four objectives are to ensure “early and improved” diagnosis of all TB patients including those with drug resistance and HIV-associated TB; following it up with “access to high-quality treatment to all patients” who have been diagnosed; particular emphasis to be given to “scaling up access to effective treatment” for those with drug resistance. Finally, it focuses on decreasing death and morbidity figures.
It has set a goal to test 48 million people for TB, and over 90 per cent of TB patients are tested for HIV during the five-year period. The emphasis is on reducing the time taken to diagnose TB, including drug-resistant TB. To this end, the RNTCP will equip all districts and medical colleges across the country with highly sensitive rapid diagnostic tests.
The compulsion to adopt a comprehensive approach, particularly early diagnosis of all TB patients and starting them on appropriate treatment, arises as in 2011 alone, the number of new TB cases that occurred was about 1.2 million. The number of deaths stood at 60,000 — nearly 165 deaths a day. Nearly one lakh new multidrug resistant (MDR) TB cases are estimated to occur every year. India has the second highest burden of MDR-TB in the world and this accounts for about one-fifth of the global burden.
The only way of reducing mortality and morbidity is by engaging the private sector, which the programme has so far never attempted to do. This, despite the fact that the private sector is the first point of contact for a majority of people, both urban and rural populations. But the 2012-2017 draft Plan intends to change this.
“Universal access will not be achieved without private sector involvement,” it notes. And its participation has to become effective for realising the goal of getting every detected case notified and “obtain information on treatment success rate.” The government in all probability will try different innovative models to “extend [its] services” to the private sector for both diagnosis and treatment.
It concedes that RNTCP has to learn from other programmes that have successfully developed and scaled-up their involvement with the private sector and community services. It will not come as a surprise if the TB control programme adopts and even replicates the best practices of other programmes in engaging with the private sector during 2012-2017.
Till date, RNTCP’s engagement with the private sector has been limited to sensitization and referrals.
“The strategic vision of RNTCP is to develop and deploy engagement models that will overcome the past barriers of mutual mistrust [emphasis added]… [and] to accept, encompass and improve TB care provided by the private sector,” notes the draft.
The intent is to go beyond private practitioners and involve clinics, nursing homes, small and corporate hospitals, chemists and private laboratories.
The TB control programme intends to subsidise diagnostic services offered by laboratories and actively discourage them from using serological testing for diagnosing TB. The government had recently banned this practice.
Since this will be first attempt to involve the private sector, several “new and innovative approaches” will be “piloted” and the successful ones “scaled-up” to meet “universal access to TB cure and control.”
The compulsion to involve the private sector arises as nearly half of three lakh patients who are retreated every year have been previously treated by private practitioners — half of TB drugs sold in India are to patients who are treated by private practitioners.
This is because, as a norm, the private sector provides “sub-optimal treatment.” Adding to it is the poor record keeping and follow-up of patients till they complete the treatment.
Though doctors, both private and public, are not supposed to start treating patients unless they are willing to follow-up till treatment completion, “there is neither commitment nor capacity in the private sector to fulfil this responsibility,” the draft notes.
But with treatment being sub-optimal, many patients end up with drug resistance. “Diagnosis and treatment of TB in the private sector is both a problem and an opportunity for the RNTCP,” the draft reads.
Medical colleges have been playing a pivotal role in diagnosing TB patients. In 2011 alone, about 15 per cent of patients were diagnosed and referred for treatment by medical colleges.“Systematic involvement of medical colleges…has been a huge success story,” it notes.
But other than medical colleges, the contribution of the private sector in detecting TB cases has been a mere 5 per cent and case management at about 9 per cent.
The goal is therefore to “achieve prompt reporting” of TB cases diagnosed in private sector, “increase the number of TB cases referred” to RNTCP and “improve the quality of care” in private sector.
Involving the private sector will be achieved through Private Provider Interface Agencies (PPIA). The PPIA will be responsible mainly for effective notification of TBG cases diagnosed by the private sector and ensuring treatment compliance. The focus will initially be on urban areas.