TB and poverty: India has third of world's poor and highest TB burden

Poverty is the greatest impediment to human and socio-economic development. "Globally, poor people and those from disadvantaged social groups suffer more illness, and are less likely to receive adequate care when ill. Poor people are more likely to have early and premature deaths as compared to more privileged in the society. Poverty represents a principal barrier to health. Tuberculosis (TB) thrives in conditions of poverty and can worsen poverty" said Dr LS Chauhan, Deputy Director General (TB), Central TB Division, Ministry of Health and Family Welfare, Government of India. He was speaking at the recently convened consultative workshop of TB and poverty sub-working group of the Stop TB Partnership in India (29-30 October 2010).TB and poverty issues are also up on the agenda of the forthcoming 41st Union World Conference on Lung Health in Berlin, Germany (11-15 November 2010). Read more

"It is a fact that TB is not a disease exclusively of the poor as anyone, rich or poor, can get infected with active TB disease, but there is a well established and widespread association between poverty and TB" said Dr LS Chauhan, who is the National TB Programme (NTP) Manager in India. India's TB programme is called Revised National TB Control Programme (RNTCP). "A vicious cycle exists between TB and poverty" said Dr Chauhan.

"Thus a pro-poor equity based approach requires that healthcare services pay special attention to the needs of the most disadvantaged groups" said Dr Chauhan.

"India is estimated to have a third of the world's poor. India is the highest TB burden country accounting for one fifth of the global TB incidence. 42% of India falls below the international poverty line of USD 1.25 a day, having reduced from 60% in 1981 as per World Bank, 2005 estimate" said Dr Chauhan.

According to the criterion used by the Planning Commission of India 27.5% of the population was living below the poverty line in 2004–2005, down from 51.3% in 1977–1978, and 36% in 1993-1994.

"According to the Mark Goodchild and other researchers whose study will get published in the International Journal of Tuberculosis and Lung Disease (IJTLD 2010), it is estimated that in 2006, TB had caused an estimated economic loss of about USD 23.7 billion to the Indian society" said Dr LS Chauhan.

"70% of the TB patients are in the economically productive age group (15-54 years) and at least 2-3 months of work time is lost per TB affected person" said Dr Chauhan.

"There is a higher mortality among patients not treated or inadequately treated as 95% of the economic loss is due to loss of life" further added Dr Chauhan.

"Thus effective TB control is seen as a positive step towards reducing economic ‘health shocks' and poverty alleviation" said Dr Chauhan.

"TB control programmes must be effective in preventing TB transmission and saving lives, addressing the needs of the poor and vulnerable communities, and collaborate with poverty alleviation initiatives being implemented in the country" said Dr Chauhan.

Dr Chauhan said that there is a diverse range of barriers that prevent poor people and vulnerable communities from accessing existing healthcare services.

- Economic barriers include cost of transportation, accommodation and subsistence, loss of wages, productivity and time

- Geographical include the distance to the TB-care services that are providing TB diagnosis and treatment

- Socio-cultural barriers include stigma and lack of knowledge of TB and available TB services

- Health system barriers include lack of health system responsiveness and potential consequences of decentralization

Many of the poor and vulnerable groups encounter more than one of these overlapping sets of barriers and have greater difficult in overcoming them than the non-poor people, said Dr Chauhan.

India's RNTCP has taken several measures to overcome these barriers and increase case detection, and anti-TB treatment, particularly among the poor and marginalized communities. For example the TB diagnosis and treatment services are well integrated within the primary healthcare system. In areas where the diagnostic services are not available there are provisions for sputum collection and transport, informed Dr Chauhan.

The diagnostic and treatment services are completely free of cost to the patient. Treatment services are decentralized to the patient's door steps so that they don't have to make multiple visits to the health facilities to avail of TB diagnosis and treatment. A network of more than 12,500 designated microscopy centres and 300,000 DOTS providers are implementing RNTCP said Dr Chauhan.

Another major step forward in RNTCP is the concept of ‘flexi-time DOTS' and workplace DOTS – flexi-time DOTS is to provide DOTS outside of regular clinic hours, as suitable to the patients – may be early in the morning or later in the evening or night. Workplace DOTS is to provide DOTS at the workplaces of the TB patients so that they don't have to commute and be absent from their work and incur loss of wage.

Dr Chauhan said that promotion of community DOTS services is another major step ahead to ensure there is people's participation in the treatment of TB patients.

Dr Chauhan said that there is a system for referral for treatment and transfer-out to ensure continuity of treatment and care among TB patients who migrate during the course of treatment. However, later in the consultative workshop of TB and poverty sub-working group, this challenge appeared to be unaddressed. There is a referral system, but no system or budget to courier the box of anti-TB drugs from one DOTS centre to other for migrating TB patients. As a result of which, a part of the medicines in two boxes goes unused. Also when TB patients migrate between India and Nepal, there are major issues – as in Nepal, the DOTS is daily therapy and TB patients are provided fixed-dose combination (FDC) therapy, and in India, DOTS in intermittent therapy, and TB patients are not provided FDCs.

There is a need to involve civil society so as to effectively link eligible TB patients to existing government of India's social welfare schemes. Also advocacy, communications and social mobilization (ACSM) activities to address issues related to lack of knowledge or TB-related stigma should be scaled up in local contexts. Tribal action plan in tribal areas/ districts should be implemented in all earnestness to suit the needs of the tribal people and to compensate for their loss of wages during treatment.

Dr Chauhan said that the performance of the programme in pre-identified poor, backward and tribal districts is rigorously monitored routinely under the programme.

The performance of the programme in tribal districts is much better when compared to the national averages. In 2nd quarter of 2010, the case detection rate (CDR) among new sputum positive TB cases at the national level was 79% whereas CDR in tribal population was 97% and poor and backward areas was 76%. Similarly in 2nd quarter 2009, the anti-TB treatment success rate at the national level was 87% whereas the treatment success rate in tribal population, and poor and backward areas was 88%.

The grant from the round 9 of the Global Fund to fight AIDS, TB and Malaria (GFATM) is dedicated for civil society engagement. Forging partnerships with the civil society organizations in the country to extend the reach of the TB control programme and move towards achieving universal access to TB diagnostic and treatment services, is a key thrust area. The National Partnerships for TB care and control in India is an example of initiatives supported by this grant.

The Indian Medical Association (IMA) and Catholic Bishop Conference of India (CBCI) are reaching out to the TB patients especially the poor patients who are seeking health services from the private and catholic health facilities.

Sharing the achievements of India's TB control programme, Dr Chauhan said that since implementation, more than 48 million TB suspects have been examined, more than 12.2 million TB patients were placed on anti-TB treatment and more than 2.2 million additional lives saved.

The global new sputum positive case detection rate is 62% (2009) and treatment success rate is 85%. India's RNTCP has been consistently achieving global benchmark of 85% treatment success rate; and case detection rate 72% (2007, 2008 and 2009).

More importantly, according to an economic impact study that was undertaken by RNTCP with support from WHO India, the RNTCP has also led to a gain in economic wellbeing of USD 88.1 billion over 1997-2006, said Dr Chauhan.

Bobby Ramakant - CNS