Overcoming India’s Tuberculosis Challenge

India’s fight against TB can only become a Jan Andolan with active and meaningful participation of civil society organisations writes Narender Yadav

On March 24, 1882, German physician and microbiologist Robert Koch announced about a path breaking discovery. It was about the bacteria that causes tuberculosis (TB). Twenty-three years later Koch received Nobel Prize in Medicine (1905) for his research on tuberculosis. His seminal work opened new avenues for TB research and treatment and the next one century saw significant progress in tools for TB prevention, diagnosis, treatment and cure. Still, TB continues to ravage humans even today and is the leading cause of death from a single infectious disease.  It is estimated that every day 4,000 people die from TB globally – a disease that is both preventable and curable.

The global health pandemic caused by SARS-CoV-2 virus further ensured that during the last 139-years of the announcement of TB causing bacteria, 2020 emerges as the worst year for TB. As per the data shared by Stop TB Partnership, nine of the countries with the most tuberculosis (TB) cases—representing 60% of the global TB burden—saw a drastic decline in diagnosis and treatment of TB infections in 2020, ranging from 16%-41% (with an average of 23%). The drop brought the overall number of people diagnosed and treated for TB in those countries to 2008 levels. “Twelve years of impressive gains in the fight against TB, including in reducing the number of people who were missing from TB care, have been tragically reversed by another virulent respiratory infection,” said Dr. Lucica Ditiu, Executive Director of the Stop TB Partnership.

According to a modelling study carried out by the Stop TB Partnership in collaboration with Imperial College, Avenir Health, Johns Hopkins and the United States Agency for International Development (USAID) global TB incidence and deaths in 2021 could increase to levels last seen between 2013 and 2016, respectively – implying a setback of at least 5 to 8 years in the fight against TB. Latest data pertaining to March 2021, from several countries, has further confirmed these predictions.  

India was one of the first countries where the dramatic decline in TB notifications was seen and Central Government’s TB notification system, “Nikshay,” reported a 70% drop between the 10th and 15th weeks of 2020. Covid-19 urgency and priorities completely overshadowed TB services in India. As Dr. Harsh Vardhan, Minister of Health and Family Welfare, Government of India himself shared in a recent online summit, “TB didn’t go anywhere when the COVID-19 pandemic hit. People just got distracted, health workers were redirected, and health systems became overwhelmed.”

However, despite the serious disruptions caused by Covid-19, Government of India is hopeful of eliminating TB from India by 2025. “The country is relentlessly fighting the pandemic from last 12 months. But even at a time when COVID is taking prioritised attention, we should not lose the sight of the goal to eliminate TB by 2025. We have continued to focus on Tuberculosis and every meeting for COVID has had TB as an agenda item,” Harsh Vardhan said recently. Prime Minister Narendra Modi also, while addressing a webinar on the budget implementation of the health sector last month, emphasized that the Central government is aiming to eliminate tuberculosis (TB) from the country by 2025.

Undoubtedly, India, in last few years has taken several critical steps to achieve the ambitious plan of eliminating TB by 2025. However, despite these remarkable commitments, the path to transform India’s promises into action, particularly after Covid-19, is long, arduous and riddled with challenges. With an estimated 2.64 million TB patients, India has the largest burden of TB globally in terms of absolute numbers. Coupled with the burden are the challenges of a largely unregulated private sector and the underlying social determinants of disease, including poverty, undernutrition, poor living conditions and risk factors such as tobacco use, which drive the TB epidemic. TB patients are lost at every stage of care-seeking. Access is suboptimal for newer diagnostic technology and drugs.

However, without acknowledging the role of civil society groups as key allies in the fight against TB, strengthening relationship with them, leveraging their reach and community presence, and harnessing their expertise in various technical and implementation areas, the goal to eliminate TB by 2025 would remain a distant dream.

“Both – government as well as the private sector (market-led models) – are not enough and there is an increasing realisation that active involvement of the civil societies is needed to eliminate TB. These organisations function outside the conventional space of both public and private, but they have the potential to negotiate, persuade  and  pressurise both these institutions to make them more responsive to the needs and rights of the patients,” says Prachi Shukla, Country Director, World Health Partners (WHP), a non-profit organisation implementing TB-focused interventions across several states. WHP’s Tuberculosis Health Action Learning Initiative (THALI), Private Providers Interface Agency (PPIA) programs have been widely acclaimed for their demonstrated success in patient-centric care and treatment, private sector engagement and increased notification. WHPs newest TB project “Closing the Gap in TB Care Cascade” institutionalizes care cascade monitoring and will prototype interventions and demonstrate models that will contribute to significant reduction of care cascade gaps while simultaneously strengthening health systems.

“Civil Society Organisations have contributed significantly to finding innovative solutions to health and wellness, through awareness generation, social mobilization, service delivery, training, research, technology and advocacy. They are an effective non-political link between the people and the government and have the comparative advantage of a bi-directional influence on community structures as well as governmental institutions; knowledge and understanding of local circumstances; and flexibility and adaptability towards local situations. Their capacity to function in difficult-to-reach, remote areas offers a unique opportunity for increased early TB case detection and treatment adherence through generating demand for services and scaling up of patient-centred care,” she further elaborates.

Similar views have been expressed in a Progress Report prepared by the World Health Organization (WHO) for United Nations Secretary General (UNSG) which was published in September 2020.  A key recommendation in the Report is the need for active investment in TB-affected communities and civil society, and to ensure their meaningful engagement in all aspects of the TB response.

If the fight against TB needs to be made truly into a Jan Andolan, a people’s movement, ensuring meaningful and impactful participation of civil society organisations is vital and decisive, particularly when there is a need to leverage COVID-19 as a strategic opportunity to end TB.

(Author is a Health Communication practitioner. Views are personal)

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