The World Health Organisation’s Global TB Report 2023, released last week, highlighted the tremendous progress that India has made in its fight against TB. It noted that since 2015, TB incidence and mortality have declined by 16 per cent and 18 per cent respectively, faster than the decline globally.
Despite this, elimination by 2025 doesn’t seem to be happening. Recent reports have outlined areas that need urgent re-alignment. Reports on drug shortages across some states, the need to sharpen TB detection exercises, and the importance of nutrition in preventing TB and reducing deaths, highlight policy challenges which, if addressed, can accelerate the country’s progress toward elimination.
The WHO report notes that in 2022, a record 24.2 lakh patients were notified in India. This number stood at 15.6 lakh in 2014 — indicating an increase of around nine lakh notifications. The government’s Ni-kshay portal also reports that till October, India has already notified nearly 21 lakh cases. Behind this success lies a matrix of transformative policies — from universal nutritional support for patients, effective engagement with the private sector, to the first-of-its-kind crowd sourcing programme to help patients complete treatment. These efforts have been backed by enhanced government funding — from Rs 710 crore in 2014-15 to Rs 3,410 crore in 2021-22. Why aren’t we getting there then?
Simple — to ensure elimination, we need to augment not just our curative but also detection capabilities. A Nature article summed it up well: “If we cannot find TB, we cannot treat TB”. While the programme has been steadfast in scaling up the more advanced molecular diagnostics, uptake has been limited. In 2022, over 77 per cent of presumptive TB patients were tested through smear microscopy, which has an accuracy of 22-43 per cent and cannot detect resistance to anti-TB drugs. In such a scenario, we are bound to miss patients and the target. Testing needs to pivot to molecular diagnostics urgently. Further, models suggest that the current testing rate of 1.2 per cent (or 1,281 per lakh population) is not enough; we must test at 4-5 per cent. Himachal is on its way to 4 per cent. During the COVID-19 pandemic, we tapped into the private sector infrastructure and conducted nearly 10 lakh RT-PCR tests every day. We must re-look at our policies and make it happen for TB testing as well. Similarly, we must reconsider screening tools. Even today, we heavily rely on symptomatic screening which has an inherent challenge. As per the ICMR’s national prevalence study, 46 per cent of diagnosed cases were asymptomatic and were detected only due to the use of chest x-rays. The availability of portable AI-enabled X-Ray applications can be an efficient and affordable alternative.
How can a country out to defeat TB afford drug shortages? One major programmatic achievement is that all positive cases are initiated on treatment. But if we fail to find cases and maintain treatment, it will be very difficult to achieve elimination. The Centre passing the buck to states at the last minute is not the best approach. Historically, the central government has procured and supplied drugs and diagnostics to states. However, states are now mandated to do so. While decentralisation is a constructive move to improve planning and delivery, it may often put them at a disadvantage in negotiating prices due to local constraints and a lower volume required as compared to the central government. Why change this process if it has worked thus far?
Second, we must recognise that ensuring treatment adherence is paramount, and we cannot afford shortage. This also brings us to recognise that better and less toxic treatment options must be considered. For instance, the WHO-recommended BPaL(M) regimen for drug-resistant patients, which has shown to have an efficacy of 85-90 per cent — more than 30 percentage points better than the existing regimen — must be made available.
Finally, we must also recognise that without a vaccine, the impact would be minimal. Rarely has a disease been eliminated without a vaccine. So it is true for TB. BCG is used in infants, but experts feel it is not enough. If India cannot develop a new vaccine, no one can.
It is time to reassess our action plan for the TB programme. In our enthusiasm to do spectacular things, let us not miss out on the basics, as there lies our road to success. Our target is ambitious but achievable.
C K Mishra is a former Secretary, Government of India and co-founder, Partnerships for Impact
