India: Holes in battle to eliminate tuberculosis

India's plans to eliminate TB as a public health problem by 2050 will remain unachievable without sustained financial support, strong political will and stringent regulation, Mahavir Golechha has said.

Golechha is a faculty member with the health economics and financing division of the Public Health Foundation of India, an academic institution.

In a report published today in The Lancet, a medical journal, Golechha has echoed concerns about the Union health ministry's Revised National TB Control Programme that some infectious diseases experts had earlier articulated.

A strategic plan to cover the period 2012 to 2017, rolled out by the revised programme, seeks to provide high-quality diagnosis and treatment for all TB patients in India.

"The (revised programme) is in many ways doing a great job, but it is not enough for the magnitude of the TB problem that India faces," Golechha told The Telegraph. "We need to see a lot more commitment."

The funds available for the revised programme have over the past two years been lower than the initial budgeted amounts.

During 2012-13, the Union health ministry had initially earmarked Rs 710 crore for TB control before revising it to Rs 557 crore and eventually spending only Rs 467 crore.

In 2013-14, the initial outlay of Rs 710 crore was revised to Rs 500 crore. Till February 2014, the programme had spent Rs 472 crore.

An estimated one million tuberculosis patients in India remain undiagnosed, Golechha said citing the World Health Organisation's global report on TB released in 2013, which primarily relies on data provided by national governments.

Standard TB treatment requires a combination of four medicines for an initial two months, and a combination of two of these four for another four months.

While government clinics that provide free treatment adhere strictly to this protocol, prescription audits have suggested that many private practitioners at times prescribe inappropriate combinations or durations of treatment.

A study published in the journal PLOS One in 2010 found that 106 doctors in Mumbai had written 63 different anti-TB prescriptions. A study in the same city in 1991 had found 80 different prescriptions by 100 doctors.

Inappropriate medications for TB can not only hurt the patient but also become a public health risk. Patients who receive wrong treatment may develop drug-resistant TB, which they may pass on to family members or close contacts.

An expert not associated with the Public Health Foundation of India said the concerns raised by Golechha were relevant and that India's cutback on investments in TB control contrasted with actions by other countries with large numbers of TB patients.

"South Africa has modernised its TB diagnosis by scaling up a new diagnostic technology to cover the entire country; Brazil is doing the same thing. In contrast, India appears to be cutting back on TB control investments," said Madhukar Pai, associate professor at the International TB Centre at McGill University in Canada, who has been closely following India's TB problem.

Golechha has also pointed out that delays in diagnosis are common in India. Many patients pass on their infection to others before they are diagnosed and receive appropriate medication, he said.

India's incidence, or the number new cases per year, of TB has remained near static at about 175 cases per 100,000 population over the past decade. India's public health system had documented over 1.2 million cases of TB during 2012.

A study released last August had found that nearly 55 per cent of TB cases in India seem associated with under-nutrition.

Pai, a co-author of that study, had then told this newspaper that unless India tackled malnutrition, it might be difficult to control TB infections in the country.

Source: The Telegraph