Why government should break its old habit of slashing down TB control budget

Today is March 24. By noon, 3,95,000 people have died of Tuberculosis (TB) the world over since the beginning of 2017. And,a third of those would be Indian.

March 24 is also World TB day. TB kills a person every 18 seconds. 

Achtung TB

Last month, I had detailed the enormity and complexity of TB’s burden in India, deserving of being declared a national health emergency outlining the following six action points that India needs to implement on priority if it is serious about going TB-free by 2025.

1. All rural and urban private doctors to join the front, allopathy or AYUSH doctors, qualified or not. Include as many allied health workers, volunteers and pharmacists to support.

2. Search, and notify all active TB patients.

3. Flag patients with drug-resistant TB, and facilitate timely availability of drugs to them.

4. Run cross-country surveillance of all high-risk groups to detect latent TB; nip TB in the bud.

5. Increase essential drug stocks in the country (public and private channels) to manage the influx of new patients and preventive disease management.

6. Arrange health insurance and financial support scheme for economically vulnerable patients with TB, especially sufferers of the drug-resistant or extra-pulmonary type ailment.

2025 is the TB elimination deadline set by finance minister, Arun Jaitley in his 2017-18 Bsudget speech.

The intent to succeed in achieving the aggressive target was re-affirmed by the Union minister of health and family welfare, JP Nadda last week at the WHO regional health ministers’ meeting.

Today, his office has planned to roll out the seven-year National Strategic Plan (NSP) to tackle TB.

Will money buy happiness?

A draft of the National Strategic Plan (2017-25) was made available in advance on the ministry’s website.

A comprehensive and well-structured document, it is indeed a reflection of the ministry’s serious commitment to the cause.

The document transparently acknowledges the challenges, and assertively puts forth legitimate demand of provisions (money, assets and people) without which, the plan may get into jeopardy.

It is framed along four strategic pillars, Detect –Treat –Prevent –Build, as follows:

1. Detect all un-notified TB cases: Those seeking care from private healthcare practitioners, and those undiagnosed, especially in high-risk populations.

2. Treat all TB patients: By making TB drugs free, and by standardising treatment protocols.

3. By ensuring full compliance to treatment regimen with mobile/internet-supported patient adherence monitoring tools.

By preventing drop-outs via a smart card-linked financial benefits schemes.

4. Prevent emergence and spread of TB: By treating latent TB carriers, and by implementing air-borne infection control measures at healthcare facilities.

5. Build enabling infrastructure and capacities to operate in a "Mission Mode": "By upscaling resources, building partnerships and, reforming current approaches for Detect – Treat – Prevent to succeed.

The proposed approach for its implementation also sounds practical and result-oriented.

It speaks of prioritising actions that will lead to a rapid improvement in the first five years, while the rest can move at a relatively lower pace in the background to support the former set.

Each of the four pillars is elaborated up to task-level, with tactical steps, timelines, and a budget allocation for the next three years.

The budgeted amount is close to Rs 5,500 crore per year until 2019.

That’s a bold ask.

It far out-surpasses the previous four year average of Rs 1,000 crore requested per year, based on which I had earlier predicted in excess of Rs 9,000 crore as the total Budget requirement for TB elimination until 2025.

In reality, as seen in the last four years, the sanctioned amount for TB control averaged at half of what was requested, at Rs 530 crore.

Will the office of the finance minister break away from its habit of slashing down the TB control budget demand by 40-50 per cent, and sanction Rs 17,000 crore for the next three years?

That firm commitment will be a key indicator of whether the TB-inflicted India of now will transform into a TB-free India of 2025.

On the bright side

The draft of the latest plan for TB control and elimination differs from all its predecessors in its pragmatism and compassion.

In the spirit of "go where the patients go", it acknowledges the critical necessity of on boarding private practitioners into the mission.

The plan proposes to take a constructive partnership approach to engage them by replacing mistrust with collaboration.

50-70 per cent TB patients in India receive treatment in the private health sector.

As low as 11 per cent are notified and tracked. For the rest, there is no information on whether they are being treated correctly.

If so, no one knows of the success rate of the treatment and the quality of care and support made available to them.

Ad-hocism and inconsistency trickles from treatment to diagnostics in the management of TB in private settings.

The new plan is expected to increase the incentive for private practitioners for notification and correct management of a TB patient until cured.

The proposed amount is Rs 2,750 — an 83 per cent increase on the current amount.

For a drug-resistant TB patient, that would come to Rs 6,750. It should motivate more private providers to sign up with the national initiative.

The draft confirms that private providers will be viewed as equal enablers of the programme.

Their training needs and grievances will be addressed with a "customer-service" approach, to keep them engaged and motivated.

For patients, TB diagnosis and drugs are envisioned to be made available at zero cost to those seeking care in the private sector too.

A smart-card-enabled cash incentive of Rs 2,000 is proposed to partly address the financial hardship of the family of a TB patient.

That, and the enhanced surveillance activity and infrastructure to monitor and alert all TB patients via SMS of all milestones and steps of their disease is expected to improve quality of care, and reduce dropouts.

A TB bill is proposed to be formulated to promote TB care as a patient’s right.

In its implementation approach, the plan aims at taking a holistic, multi-sectoral approach to strengthen the entire health system for TB elimination.

It speaks of reforms in the organisational structure, management teams, and governance structure of the existing TB Control bodies.

It also covers air-borne infection control and the community and institutional level to cease further spread of infection.

The plan assumes a huge dependence on information and communication technology to improve surveillance, to disseminate and track information, and to manage financial disbursements. Nikshay — an aptly-named, e-platform(launched in 2012) is expected to become the mainstay of the programme.

The plan assumes that Nikshay’s link to AADHAR and Pradhan Mantri Jan-DhanYojna will enable seamless transfer of patients’ benefits and physcians’ incentives as digital payments.

So far, Nikshay’s performance has been pale but unsurprising. 70 per cent of India’s Gram Panchayats do not have network connectivity, let alone Primary Health Centres in villages.

Even with increased private sector participation, its success will remain jaded until BharatNet’s optical fibre network reaches all villages, which will take until 2023.

The current plan hasn’t taken this mission-critical dependency into account.

Is 2025 possible?

The next two years will be critical to set the processes in place, followed by firing the momentum in 2019.

The first positive signal will be sanctioning of the requested budget with immediate effect.

That would change the odds in its favour by manifold.

Following that, implementation will hold the key to its success.

Also read: Why tuberculosis is still eating into India