Tuberculosis control needs a complete and patient-centric solution

Dr Madhukar Pai, Prashant Yadav and Ravi Anupindi *

Cycle rally marks World TB Day observance on March 24 2014 :: Pix - Hueiyen Lanpao

Whether it is mobile phone service or vacation travel, good businesses know that success depends on providing a complete and customer-centric solution. Should patients with tuberculosis not be offered a complete solution that is patient-centred? After all, millions are affected and a large market at the base-of-the-pyramid (BoP) remains unserved.

A complete and patient-centric solution will not only include care that meets the International Standards for Tuberculosis Care, but also be delivered with dignity and compassion, grounded in the reality of patients’ lives as they navigate the long pathway from symptoms to cure. Such solution-based innovation requires a systems-thinking approach that must place patients at the centre of design strategies, recognize their clinical and psycho-social needs, and be cost-effective.

Because tuberculosis requires long-term treatment and involves many actors in the value chain, there needs to be an entity which, with appropriate financial support from external agencies, can orchestrate a complete solution that is affordable and locally accessible for patients.

Are tuberculosis patients in high burden countries currently getting such a patient-centric solution? Let us consider India, which accounts for quarter of all tuberculosis cases in the world. Whether patients in India seek care in the public or the private sector, they struggle to get a complete solution.

While India’s Revised National Tuberculosis Control Programme (RNTCP) has done well to reach scale and provide free diagnosis and treatment for patients with drug-sensitive disease in the public sector, the programme falls short in making sure that all patients get screened for drug-resistance and in ensuring adequate therapy for all patients with multidrug-resistant TB (MDR-TB) and extensively drug-resistant TB. Of the estimated 64,000 cases of MDR-TB in 2012, only 17,373 cases were diagnosed under the RNTCP.

The diagnostic infrastructure in the public sector relies primarily on sputum smear microscopy that cannot detect drug resistance. It is only when patients fail to get better on standard treatment, or have recurrence of tuberculosis, that they get screened for MDR-TB, resulting in morbidity, continued transmission, and movement of patients from the public to the private sector.

Recognizing these problems, the RNTCP is actively scaling-up capacity to diagnose and treat MDR-TB. If adequately funded and successful, these initiatives should improve patient experience in the public sector.

But the stark reality of tuberculosis in India is that 50% of all cases are managed in the private sector, where the quality of tuberculosis care is suboptimal with inaccurate diagnosis, non-standard drug prescriptions, and limited effort to ensure treatment adherence. Also, private practitioners often do not screen for drug-resistance and empirical antibiotic abuse is rampant. All this means that drug resistance can emerge or worsen, with poor outcomes. Lastly, the high out-of-pocket expenditure in the private sector can be catastrophic.

Are there examples of initiatives that address the above systemic problems?

Operation ASHA is a non-governmental organization in India that extends the RNTCP model, and uses public sector diagnostics and drugs, to orchestrate a solution by establishing community-based treatment centers and ensuring adherence using local community providers and partners. It also leverages biometrics to increase efficiency and effectiveness. It relies on donors and the public sector for funding. This social enterprise model, however, does not offer a solution to patients who seek care in the private sector. Outside of India, Operation ASHA is now replicating its model in Cambodia.

World Health Partners (WHP) is a donor-supported social marketing and social franchising model that delivers affordable reproductive and primary care (including tuberculosis) in underserved rural areas, by leveraging local entrepreneurs and informal providers, and by connecting them to the formal sector and specialists via telemedicine.

Initiative for Promoting Affordable, Quality TB tests (IPAQT), a coalition of more than 60 private laboratories, supported by non-profits like the Clinton Health Access Initiative, has increased the availability and affordability of WHO-endorsed tuberculosis tests. Although IPAQT is addressing the problem of suboptimal diagnosis, it does not cover treatment.

In Bangladesh, BRAC's tuberculosis programme with shasthya shebikas has been successful in the public sector. This model is now creating linkages with private providers. In addition, they have created partnerships with garment industry owners in export processing zones that provide factory workers with better access to tuberculosis diagnosis and treatment utilizing BRAC’s infrastructure.

With donor support, Interactive Research and Development (IRD) and partners are expanding access to Xpert MTB/RIF (Cepheid Inc, CA), a WHO-endorsed test, in the private sector in Dhaka, Jakarta and Karachi, through mass verbal screening in private clinic waiting rooms, and referrals for computer-aided digital X-ray diagnosis. This model includes management of comorbid conditions such as diabetes and chronic obstructive pulmonary disease, to generate revenue for this social enterprise.

RNTCP recently announced “universal access to quality diagnosis and treatment for all tuberculosis patients in the community” as its goal in the new National Strategic Plan. Recognizing the need to leverage the private sector in developing a solution, the plan includes engagement of the private sector using “Public Private Interface Agencies” (PPIA) to enlist, sensitize, incentivize, and monitor diagnosis and treatment by private providers, to provide patient cost offsets such as subsidised diagnostics and free drugs to privately treated patients, and improve case notifications to the RNTCP. Ongoing PPIA pilot projects in Mumbai and Patna should inform policies for refinements and scale-up of this model.

All these models are promising, but the goal of a complete, patient-centric solution is still elusive. Continued innovation in the development of scalable, sustainable and replicable business models to provide such solutions is critical. To improve accessibility and affordability, many of the models will depend on community workers and coordinators, underscoring the need for well-designed strategies for their recruitment, training, incentivization, and performance management. Information and communications technologies will also be critical for success.

Solution-centric approaches have shown promise in several other BoP contexts, from affordable eye care to artificial limbs. By using product and process innovations, often with community champions, these models have shown that it is possible to serve the BoP market needs effectively and efficiently and with compassion and dignity. Individuals with tuberculosis deserve nothing less.

(First published in the Lancet Global Health on 24th March 2014)