Tuberculosis is a major global health problem. According to the World Health Organization, there were an estimated 9.6 million new TB cases globally in 2014, 24 percent of which were in India.
India is one of the few countries that has achieved all the MDG indicators related to the disease. However, the burden is still immense. And despite a robust TB control program that reports over 1.4 million TB cases annually, nearly 1 million cases are still “missed.”
Most of these “missed cases” are people who seek treatment in the country’s large private health care sector in the country and go unreported. Unreported cases are less likely to receive quality treatment, which leads to poor outcomes for individual patients while increasing the risk that drug-resistance will emerge.
To address this issue, the government of India in 2012 declared tuberculosis a notifiable disease, obligating every health care provider to report all TB patients they diagnose and/or treat. However, even after three years, the notification from private health care providers remains poor. In addition, unlike the public sector, which follows directly observed treatment, or DOTS — the international standard — there is a no formal mechanism in the private sector to support patients to adhere to the entire six to nine months of therapy. This lack of support leads to treatment interruption, drug resistance and even death.
Unless private health care providers are successfully engaged in reporting and supporting the patients they manage, it is unlikely that India will achieve the ambitious target of ending TB by 2035. If we don’t end TB in India, we will not end the disease globally.
3 hurdles to getting proper treatment
First, the private sector in India is diverse, ranging from unqualified providers to highly regarded specialists; from informal clinics in the rural areas to high-tech corporate hospitals in the cities. This diversity begets complexity and requires multiple strategies to engage this heterogeneous group of providers.
Second, studies have shown that private providers, generally speaking, are unaware that it is mandatory to notify the government each time someone is diagnosed with tuberculosis. In fact, there are prevalent misconceptions that such reporting could attract unwarranted scrutiny related to their clinical practice and income.
Third, there have been no convenient mechanisms to notify and support TB patients, thus creating an additional burden for the already busy private provider.
Are there any solutions?
The International Union Against TB and Lung Disease, in collaboration with Apollo, a leading private hospital chain and supported by Lilly MDR TB Foundation, undertook a project in India that provides evidence for a new technology-based approach to supporting TB patients throughout the course of treatment.
Following discussions between The Union and physicians from the Apollo Hospital in Hyderabad, we conceived the project in early 2015 in order to find an efficient and cost-effective solution to notify and provide treatment adherence support to patients. Innovative software was developed, which facilitated notification of patients and simultaneously initiated treatment adherence support through daily SMS text messages and twice-weekly interactive voice response calls, or IVRCs.
From June 2015 to March 2016, 200 patients were registered at the hospital, with all of them successfully notified. An analysis of over 3,000 IVRCs showed that nearly 95 percent of the patients were taking their treatment regularly. In addition to that, over 90 percent of the patients found the reminders and IVRC helpful in adhering to treatment. The total cost of the treatment support for six months (usual duration of TB treatment) is just $2.
What are the lessons?
Success hinged on several important factors. It was a collaborative effort, with equal participation and commitment from the private sector, rather than being thrust upon them for compliance.
The project looked at feasible options and adequately deployed widely used and cost-efficient strategies for supporting treatment adherence. This was a practical demonstration of “e-DOTS,” which is now being widely encouraged. Both the government and the private provider allowed linking of their systems with the interface software — an essential, but not inevitable, collaboration.
The initiative served as an opportunity to update the physicians on management of TB following standards of care, dispelling misconceptions about TB notification and reminding them about their public health responsibility to notify and ensure treatment adherence — while offering them a convenient solution for the same.
The repeated reminders through SMS and calls emphasized the importance of regular treatment to the TB patient.
This added up to a win-win situation for all: The government received the notifications; the private providers ensured compliance for notification and retained the patients; and the TB patients received treatment adherence support at no additional cost.
Engaging the private sector is critical for ending TB in India, and this requires collaborative models that are mutually beneficial and innovatively use modern technology to reach out to and support patients. With several thousand private hospitals in the country, there is a potential to scale this initiative with minimal investment and recurring cost — along with the prospect of using the same model to support treatment adherence for other chronic conditions such as diabetes and cardiovascular diseases.
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