The Joint Monitoring Mission 2015 has come down heavily on the Revised National Tuberculosis Control Programme (RNTCP) and the Ministry of Health and Family Welfare for their inability to handle the MDR-TB crisis in the country. The report released last month reflects on the findings, conclusions, and recommendations made by it in 2012.
Despite its inability to diagnose drug-resistant TB, the national programme’s heavy dependence on the century-old, insensitive smear microscopy as a primary diagnostic tool has been strongly criticised. Besides the lack of sensitivity, the microscopy is ill-equipped to diagnose drug-resistant TB. This is particularly worrying as the number of drug-resistant cases is steadily increasing.
The Standards for Tuberculosis Care in India (STCI) — a document drawn up by the Central TB Division in consultation with the WHO and national TB institutes — advocates drug sensitivity testing for all presumed MDR-TB cases. However, this may not become a reality in the near future. “Progress is threatened by slow uptake of the new molecular test” the JMM says. “Procurement of these tests is unaccountably delayed.”
“The RNTCP currently treats patients without knowing their resistance profile,” states the Joint Monitoring Mission report. This along with its current regimen of thrice weekly drugs even to those with prior resistance has been associated with “failure and amplification” of resistance to rifampicin drug. “It is therefore likely, under programme conditions, to be generating more MDR cases,” it says.
While private doctors treat patients with daily dosing, the RNTCP follows a thrice weekly strategy. The report has emphasised the need to “accelerate implementation of the transition to daily dosing.”
According to the report, turning to “universal drug susceptibility testing and switching to a daily regimen with adherence support” can go a long way in addressing the problem of unwittingly exacerbating TB drug resistance in the country.
According to Dr. Soumya Swaminathan, Director of the Chennai-based National Institute for Research in Tuberculosis, the RNTCP is planning to start daily dosing using fixed dose combination in 5-6 States and then expand it to the rest of the country. “RNTCP is currently procuring drugs to make this shift,” she said.
Another failing of the TB programme pertains to the mandatory TB notification by the private practitioners. “In spite of mandatory notification, TB patients [treated by private doctors] are not notified to the RNTCP,” the report says. It wants the Ministry to develop e-Nikshay, an advanced version to the existing Nikshay system for notifying TB patients.
The national strategic plan (NSP) for TB control for 2012-17 developed by the Union Ministry of Health & Family Welfare had raised the bar for tackling the rapidly growing TB epidemic in the country. The main goals of the strategic plan are to provide universal access to early diagnosis and treatment and improve case detection.
Due to faltering on both counts, the JMM reports that the “implementation of the NSP for 2012-2017 is not on track — projected increases in case detection by the RNTCP have not occurred, vital procurements are delayed and many planned activities have not been implemented.”
Worse, about two-thirds of the recommendations made by the Joint Monitoring Mission 2012 have “not been fully implemented.” For the most part, the Central TB Division has “completed the policy work requested. Work is held up for lack of timely decisions, especially at central level,” it states.
With the cost of treating a person with TB going up to 39 per cent of the household’s annual expenditure, the report has recommended that the Ministry of Health minimises the out-of-pocket expenditure by families by “supporting the cost of TB testing and [providing] free drugs.” It also wants the government to eliminate taxation on TB diagnostics and drugs considering TB as a public health emergency.
In order to ensure that patients receive the standards for TB care for India, the JMM has recommended that the government establishes a “state-of-art TB surveillance system for capturing all TB cases, public and privately-treated.” This is essential for the country to “capture and respond to local and focal epidemics.”