India has one of the most severe burdens of tuberculosis (TB) in the world, accounting for one-fifth of the global incidence. TB is India’s leading cause of adult illness and death from a communicable disease. Its greatest impact is on the poor. In 2007, India had an estimated 1.98 million new TB cases, and 331,000 persons died of the disease. Of the new cases, 870,000 were infectious, each on average infecting another 10 people. The disease — an ancient scourge — is a major barrier to the country’s social and economic development. Most of those infected are 15- to 59-year-old adults, the most economically productive segment of society. An estimated 100 million workdays are lost due to the illness every year, resulting in nearly US$3 billion in indirect costs.
In 1993, the Indian Government started to treat tuberculosis patients with the World Health Organization-recommended Directly Observed Treatment Short-course (DOTS). Left on their own, many TB-infected patients fail to take the entire regimen of medication, contributing to the spread of drug-resistant TB. With DOTS, healthcare workers observe patients as they take their medicine. The results of a series of pilot projects financed with Swedish and Danish bilateral assistance were so encouraging that in 1997 the Indian Government formally launched the DOTS strategy as the Revised National TB Control Program. The first IDA credit (1997- 2005) allowed rapid expansion of the DOTS strategy throughout the country. By providing free diagnostic and treatment services through public or non-public institutions, the project ensured the availability of TB diagnosis and treatment to all citizens regardless of their economic status. Approximately 5.6 million TB patients were placed on the DOTS regimen. Full nationwide coverage of the DOTS strategy was achieved in March 2006, covering over one billion people. The ongoing second IDA credit (2006-11) focuses on consolidating services; expanding DOTS services to poor, tribal, and hard-to-reach groups; and addressing emerging threats like HIV/TB co-infection and multi-drug resistant TB — a dangerous and difficult-to-treat variant.
Since 1997, the DOTS strategy has raised TB awareness and improved detection and cure rates dramatically. With better DOTS-based diagnostic facilities, more than 9.5 million people suffering from TB between 1997 and 2008 were diagnosed and placed on treatment, thus saving more than 1.7 million additional lives. At the national level, case detection rates reached 70 percent, achieving global targets. Cure rates for those placed on treatment tripled from 25 percent in 1997 (the pre-RNTCP era) to 86 percent in 2009 exceeding the global target of 85 percent. Deaths from the disease were cut sevenfold from 29 percent to 4 percent during the same period.
Highlights:
- India met global targets for TB detection and cure. At the national level, India has achieved the global targets for case detection (70 percent) while maintaining cure rates above the global target of 85 percent.
- Diagnosis conducted in the villages. A key reason for success of DOTS is that the entire program is decentralized, with diagnosis done in the villages rather than in district hospitals. Quality-assured diagnostic facilities are available through more than 12,000 microscopy centers.
- Local health workers or trained volunteers implemented the program. More than 300,000 local health workers or trained community volunteers ensured that patients adhere to their drug regimen. A coalition of associations of medical professionals of different disciplines is engaged in promoting international standards for TB care. Also participating are 267 medical colleges and 2,500 NGOs. More than 19,000 private practitioners have been sensitized and trained across 6 states.
- Cross-referrals between health programs experienced a continuous rise. In 2008 alone, more than 160,000 Integrated Counseling and Testing Center clients (for HIV) were referred to the TB program for diagnosis; and 130,000 TB patients were tested for HIV. This has greatly controlled HIV/TB co-infection.
- Focus increased on drug-resistant TB. The spread of multi-drug resistant TB has been prevented by the provision of quality DOTS services and special patient management under the “DOTS-Plus” program. DOTS-Plus sites were initiated in Gujarat and Maharashtra and have now been scaled up to 6 other states to provide the extra care required.
- Services provided free to poor. Free TB diagnosis and treatment services were made available to all citizens, saving the poor from being driven deeper into poverty by the cost of medication and treatment.
- Reporting decentralized, analysis streamlined. Each of the 600 districts in the country directly enters data into the Quarterly Program Status Reports, which are posted on the program website. This enables central and state governments to focus on under-performing states and districts.
IDA has helped scale up the Revised National TB Control Program nationwide. The first IDA credit for US$142 million ran from 1997 to 2005. The second credit, from 2006 to 2011, is ongoing and provides US$170 million. IDA has contributed to several innovations in the TB control program over the years, including the establishment of a strong cross-referral system between the TB and the HIV/AIDS programs, the pioneering of the public-private mix for diagnosis and treatment of TB, and the initial expansion of laboratory capacity to address the increasing problem of multi-drug resistant TB.
The implementation of a program of such scale and magnitude involved a wide range of partners: 267 medical colleges, 2,500 NGOs, more than 19,000 private practitioners, and over 80 corporations. A wide network of community volunteers has been developed; more than 300,000 local health workers or community volunteers provide assistance under the program, greatly boosting the effectiveness of TB control efforts. Other donors — DFID, USAID, Danish bi-lateral assistance, Global Drug Facility, and the Global Fund for AIDS, Tuberculosis, and Malaria (GFATM) — have gained confidence in the program and provided technical assistance and additional financing. The cost of the Revised National TB Control Program varies and has been increasing with greater focus on multi-drug resistant TB and increasing support from GFATM. Between 2002 and 2007, the total cost of the Revised National TB Control Program was estimated at US$300 million with supported in approximate proportion as follows: Government of India, 13 percent; IDA credits, 54 percent; grants from bilateral donors (USAID, DANIDA, DFID), 18 percent; and GFATM, 14 percent.
To achieve the Millennium Development Goal of cutting in half the 1990 prevalence of TB by 2015, the project’s excellent performance should be sustained and extended to all districts in the country. To this end, the decentralized provision of high-quality DOTS services remains the major priority of the TB control program. The Ministry of Health and Family Welfare plans to focus on low-performing districts in order to further improve the overall case detection and treatment rates. The Ministry plans to step up the diagnostic and treatment capability to reduce the impact of multi-drug resistant TB since it is increasingly recognized as a major public health threat. IDA will assist in this expansion plan, ensuring that more intermediate reference laboratories are established and that staff capacity is enhanced, particularly in case management.
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