Towards an Equitable and Effective TB Care System in India

Context:

With an estimated 2.8 million new cases annually, India accounts for more than 25% of the global tuberculosis (TB) burden. 

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• Over half of TB patients in the country seek care in the private sector, where treatment affordability and adherence to standardised protocols remain concerns. 
• In contrast, public healthcare facilities provide free treatment but often lack a patient-friendly environment. 
• Addressing these challenges requires a comprehensive, patient-centric approach that integrates public and private healthcare systems, ensuring accessibility, affordability, and adherence to best practices in TB care.

Strengthening Public-Private Collaboration

• Public: Government hospitals offer structured clinical algorithms, contact tracing, and free medication, but patients often perceive public healthcare as suboptimal in terms of drug quality and diagnostics. 
• Private: Meanwhile, private healthcare settings provide a more comfortable atmosphere but may lack strict adherence to national TB treatment protocols and patient follow-up mechanisms. 

• Coordinated Approach: Bridging these gaps through a sustained public-private partnership is crucial for improving TB outcomes. 
  • A well-coordinated approach can provide patients with flexible treatment choices while maintaining standardised diagnostics, treatment monitoring, and drug adherence across both sectors.
• Hybrid Model: Additionally, many drugs for drug-resistant TB are currently available only in government hospitals to prevent misuse and resistance development. 
  • A hybrid model, allowing supervised access to these drugs in private hospitals while maintaining compliance with national treatment guidelines, could be a game changer.
  • A collaborative system with flexible treatment pathways, rigorous monitoring, and equitable drug distribution would ensure patient-centric care without compromising treatment standards.

Challenges of TB Care in India

• Barriers: Early diagnosis, family and workplace support, medication adherence, and financial stability play critical roles in a patient’s recovery. 
• Stigma: Many patients face stigma, fear, and financial distress, which can lead to treatment discontinuation. 
• Social Determinants: Social determinants such as malnutrition, disabilities, and economic hardships further exacerbate TB-related challenges.
• Perceived Notion: Despite being an airborne disease, TB continues to be perceived as an affliction of the poor, leading to public apathy and underinvestment in its control. 
  • Addressing this issue requires a systemic shift towards prioritising TB care at all levels—government policies, corporate responsibility, media engagement, and community-led advocacy. 
• Investments: Investing in well-trained healthcare workers, improving drug availability, and strengthening community-based monitoring systems are fundamental steps toward building a resilient TB care framework.

Expanding TB Control Strategies

• India has made significant progress in TB detection and treatment through strategic interventions. Key advancements include:
  • Expansion of molecular testing for rapid TB and drug-resistance detection.
  • Introduction of the shorter, all-oral BPaLM regimen for drug-resistant TB.
  • Doubling of nutritional support under the Ni-kshay Poshan Yojana (NPY).
  • Enhanced community involvement, including TB survivor-led advocacy initiatives.
• These measures have contributed to a 17.7% decline in TB incidence, from 237 per 100,000 people in 2015 to 195 per 100,000 in 2023, alongside a 21.4% reduction in TB-related deaths. 
  • However, further efforts are needed to integrate TB services into India’s broader healthcare system and ensure universal access to high-quality care.

Decentralising and Integrating TB Care

• The Ayushman Bharat National Health Protection Scheme, launched in 2018, has played a pivotal role in integrating TB care with primary healthcare services. The scheme encompasses:
  • Ayushman Arogya Mandirs (AAMs): These centres serve as the first point of contact for TB diagnosis, treatment, and preventive care, reducing patient costs and travel burdens.
  • Pradhan Mantri Jan Arogya Yojana (AB-PMJAY): The world’s largest health insurance scheme, which should expand coverage for TB treatment across both public and private healthcare providers.
  • Strengthened private-to-public referrals: Ensuring patients unaware of free TB services or unable to afford private care are guided towards public treatment facilities.
• Community health officers at AAMs must be trained to identify high-risk TB patients, provide nutritional and social support, and refer critically ill patients for hospital admission when necessary.

Towards Equitable TB Care

To accelerate progress toward TB elimination, five key actions are required:

• Scaling Up Person-Centred Care: Interventions such as Tamil Nadu’s “TB death-free project” (TN-KET) have shown success in reducing TB mortality through targeted identification and referral of vulnerable patients. Similar models must be expanded nationwide to enhance TB care outcomes.
• Recognising Intersectional Health Barriers: Social factors like gender, caste, disability, and economic status influence TB care access. India’s National Tuberculosis Elimination Programme (NTEP) has adopted a gender-responsive framework, which must be expanded to address broader social determinants.
• Integrating TB with General Healthcare Services: Screening for related conditions like chronic obstructive pulmonary disease (COPD), asthma, diabetes, and depression alongside TB diagnosis can improve overall health outcomes.
• Reducing Out-of-Pocket Expenditure (OOPE): Expanding social protection through wage-loss compensation, nutritional support for families, and livelihood initiatives for TB survivors can mitigate financial distress during treatment.
• Improving Public Awareness: Lessons from COVID-19 communication strategies should be applied to TB awareness campaigns. Dispelling stigma, educating the public on transmission and prevention, and ensuring accessible information on drug-resistant TB are critical.

The fight against TB requires coordinated efforts across multiple sectors, including healthcare, social welfare, corporate partnerships, and media engagement. With a holistic, equitable, and decentralised approach, India can set global benchmarks in TB care and universal health coverage.