TB challenges in India

According to the recent WHO Global TB report, India, annually, is hit by approximately 2 million new TB cases. Almost 50% of them are infectious TB (sputum smear positive Pulmonary TB) and if remains undiagnosed and untreated, each of those infectious TB cases has the capacity to infect 10-15 persons per year. So TB has tremendous potential to spread fast in a densely populous country. And India is one of such brightest examples in the globe.

Many TB cases receive treatment at the private sector. Those cases are not reported to anywhere so we have no idea about their numbers/estimates. The public-private mix (PPM) schemes have been initiated to imrprove involvment of the private doctors in the National TB Program (RNTCP) of India.

HIV is a very powerful enhancer of TB epidemic that has been already experienced in Sub-Saharan Africa where as high as 40% of the country's population is infected by HIV. High load of HIV can easily trigger TB in a country with equally high TB burden.

Fortunately, for India, HIV is not that strong driving force of TB epidemic with the low prevalence rate (0.3%). Approximately 5% of the TB affected population is co-infected by HIV. The key challenge of TB/HIV collaboration is to reach the HIV infected population with adequate and appropriate TB services in politically and geographically difficult places like North-Eastern states, and in highly vulnerable states like UP, Bihar, Orissa, WB etc where public health systems are comparatively weaker as a result of inadequacies in infrastructure and political committment.

On the other hand, TB is a bigger threat in a country where more than 40% of the total population (1.2 billion) is estimated to be infected by TB. The key driving forces of TB in India are poverty, malnutrition, unhealthy living, smoking, migration and increasing trend of diabetes. Though the country has achieved the targets of 70% case detection rate and 85% cure rate, there are a number of districts consistently showing poor performances in terms of low case detection and cure rates. Besides, there are greater number of high risk population groups who have still extremely poor access to TB services and information. That include poor homeless people in urban set ups, slum dwellers, tribal groups, sex workers, drug users, prisoners, migrants, refugees, internally displaced people etc. The support of NGOs is a must to help those underprivileged and underserved population groups utilize the TB services from the National Program. RNTCP has already started schemes that can be adopted by the NGOs to provide meaningful contribution to the National TB care and control initiatives. But the responses of the NGOs, so far, are not encouraging like the HIV program.

Engaging the private doctors in the TB program is one of key strategies to achieve the goal of universal access. The PPM strategy has mainly 2 objectives: 1) improve TB case reporting from the private sector, 2) encourage private sector to follow the RNTCP drug regimes and the DOTS strategy. It targets both the qualified and unqualified private doctors. So far the experience of PPM is mixed but remains always challenging.

RNTCP will be going into its third phase from 2011 with the target of 100% TB case detection that will make the task of TB care and control steeply challenging in the coming days.

Sugata Mukhopadhyay

Universal Health

TB Programs should take more responsibilities now to strengthen the efforts for TB/HIV collaboration

The TB programs of the countries are gradually shifting focus on 100% case detection as part of universal access. This means responsibilities of the TB programs will increase many folds, especially towards the TB/HIV component in terms of facilitating TB case detection among the HIV high risk groups and PLHIV at the community level, through strategic advocacy, communication and social mobilisation (ACSM) approach.

The ACSM component is still weak in TB/HIV collaborative programs. The NGOs and CBOs working with HIV high risk groups in HIV prevention programs have shown weak linkages with the TB programs. Similarly, PLHIV networks and home based care programs are not well connected with the TB initiatives. TB case detection among HIV program participants is happening chiefly in the healthcare facilities. Those not accessing the services are remaining with undiagnosed TB and seeking treatment either in private or indigenous healthcare services, often gets maltreated/incompletely treated/undertreated for TB, thus also increasing the risk of MDR-TB.

It is a big challenge for the TB program to reach the HIV program participants, the high risk groups and infected and affected population with the required package of awareness, information and services. This can be achieved through an effective collaboration with the NGOs, CBOs and PLHIV networks, especially those who are already implementing HIV prevention, care and support programs.

In India, Round 9 TB project supported by GFATM is expected to improve and expand the ACSM component in the TB/HIV collaborative program of the country. The project will be covering 374 low performing districts of India and aiming at facilitating TB case detection in hard-to-reach areas and marginalized population including the HIV high risk groups, infected and affected people. The project will be involving the PLHIV networks in the TB program through their sensitization and capacity building on TB. Moreover, the project will be responsible to popularize the NGO-TB schemes and help the NGOs to adopt the schemes. Those schemes generally provides good opportunities equally to the NGOs already working in HIV sector to contribute significantly to the TB sector as well in terms of enhancing ACSM and TB case detection in the high risk groups, infected and affected population.

We are strongly hopeful.

Sugata Mukhopadhyay
Universal Health

Story a highly motivated TB Health Visitor of Gujarat

I met this TB Health Visitor during my recent trip to Rajkot city of Gujarat.  He requested me not to disclose his original name. I will call him Babubhai in this write up.

My primary objective was to visit the Targeted Intervention (TI) HIV project for female sex workers and MSM (man who has sex with man). The project was implemented by a local NGO of Rajkot with the support of Gujarat State AIDS Control Society. Babubhai was present in the same meeting I had with the TI project staffs.

Babubhai developed a healthy relationship with the TI project staffs. He used to bring the TB patients to the TI project counselors for counseling before referring them to ICTC for HIV testing. He actively took part to disseminate key TB messages to the HIV high risk groups targeted by the TI project. It is his initiative that prompted the TI project staffs to refer the suspected TB cases (cough for more than 2 weeks) successfully to the local DMCs from the community of female sex workers, their clients and MSM groups. He set up an encouraging example of ACSM indeed.

His rapport with the local private providers (non MBBS) was phenomenal. Those providers were closely associated with the TB program because of Babubhai’s frequent interaction with them and continuous motivation. ‘It is very important to meet the private doctors in frequent intervals during the free hours of their clinic and repeatedly appreciate their services for the National Program. I learnt the technique from the medical representatives of the pharmaceutical companies. If they can make so many visits to the doctors to sell the products of their companies, why can’t I do the same for the sake of my National Program?’ commented Babubhai.

I strongly felt he probably said the last word that can definitely bring success to the PPM (Public Private Mix) strategy.

Sugata Mukhopadhyay
Universal Health

Do we really need those powerful donors?

Public health projects are donor-driven except a few. It is the donor who, most of the time decides the fate of the programs. The programmatic activities are performed as long the funds are available. After sometimes, it so happens that activities become routine, not need-based and the program gradually starts losing its gravity. One prominent example is World AIDS Day. It is no more appealing to those who need the services and attention maximum as far as the HIV/AIDS epidemic is concerned. World AIDS Days are observed mostly because the funds are still available to celebrate them. Another striking example is Pulse Polio Program. In countries like India, Pulse Polio Programs have overtaken Routine Immunization activities in states like Bihar and UP because of the mounting pressure of the external donors and agencies and uninterrupted flow of funds. Pulse Polio is completely a donor-driven program but can polio be eradicated chiefly by the supplementary immunization activities?

The value of true partnership, though strongly advocated and highlighted, is not practically visible in the donor-recipient relationship.  The donor enjoys the heavier side of the power dynamics and freely dictates the terms and conditions to the recipients who have no option other than obliging them. The beneficiaries, in whole of the negotiation process with donor, remain in the backseat. Their needs and challenges are not expressed in their languages and emotions but through the reflections of the ‘so called’ specialists representing the recipients’ side. It is generally perceived that poor and vulnerable people having no/poor literacy generally lack capacity to deal with the donors and handle their tricks.

Community based organizations and networks have been established over years, especially associated with AIDS programs. These bodies are represented mainly by literate. English-speaking and smart folks. How many poor and underprivileged people are linked to those networks and enjoying the benefits is still doubted.

So, how long the donors will exclusively enjoy the overall authority of the public health projects? How long they will keep on providing funding to address the issues that are not exactly located in the agenda of the beneficiaries? How long they will enjoy the control over the projects and exerting the right to withdraw funding as per their own decisions and convenience without thinking a bit about the agonies and helplessness of the beneficiaries? How long they will remain ‘God’ of the public health and development sectors?

The answer is till the time the public health projects become truly the people’s program.  

About five years back, while making a field trip to Chhattisgarh I came across the community clinic which was established by the poor people of the slum.  They invested their hard-earned money into setting up their own health-centre within their slum. A local woman donated a part of her house to provide space for the clinic. The joint subscription of the local people enabled to purchase furniture including electric devices like ceiling fans and lights, medical instruments and medicines. A part-time lady gynecologist and full-time nurse were hired as salaried staffs of the clinic. Subsequently, when clinic became busier, the local district hospital sent regularly their ANM (Auxiliary Nurse Midwife) with vaccines to the clinic to immunize the local children. The local hospital also promised the slum dwellers to provide free supply of medicines and a larger space for the clinic in the near vicinity.

Five years down the line, the community clinic is still functional. The doctor and nurse are still associated with the clinic with the same kind of enthusiasm and spirit. The linkages with the local district hospital have become stronger. The local people’s investment to ensure their own healthcare is giving the dividend now.

Where do you find a better model of private-public partnership than the community clinic? Do you need an external donor to initiate and support such models?

Nothing actually can match with the power and commitment of the people.    

Sugata Mukhopadhyay
Universal Health

Prevention of sexual route of HIV – Asian and Indian context

In any kind of multiple sexual relationship scenario, correct and consistent use of condoms in all penetrative sexual acts – peno-vaginal, peno-oral nad peno-anal  (100% condom use) should be promoted as the priority strategy and it should be sustained over a period of time to achieve the desired result of prevention of HIV transmission via sexual route. Asia has already experienced the good results of 100% CUP  with the high risk communities like sex workers because the condom promotion strategy was adopted as one of the primary strategies during inception of the AIDS control programs of the Asian countries during the nineties.  HIV prevalence among sex workers have already shown downward trend in many of the Asian countries for last several years that clearly indicates effectiveness of 100% CUP to reduce HIV transmission in the context of concurrent multiple partnership within the sex work set ups. The HIV prevention projects should be designed to establish this prioritized primary intervention with the strategic advocacy in place to address the socio-cultural and religious issues that generally revolves around use of condoms.

The Indian context has actually brought the revolution in the HIV/AIDS sector by giving birth to the structural intervention concept which does not stop at BCC but tries the explore the underlying and deep rooted causes of vulnerability to HIV, especially with the high risk groups. Thus for sex workers it is their profession and criminalized status in the Asian countries that increase their vulnerability to HIV, not just behavior. The Indian programs have been designed to address the structural issues to modify the risky behaviors through interventions like collectivization of the community members and their empowerment, formation of CBOs (Community Based Organizations) and finally community ownership by keeping the community members at the driver's seat of the programs.

At the same time prevention initiative remained the topmost priority in India from the beginning of our AIDS control program with maximum resources (almost 70%) allotted to support the prevention activities.

Sugata Mukhopadhyay
Universal Health