Tuberculosis control needs a complete and patient-centric solution
Authors: Madhukar Pai, Prashant Yadav, Ravi Anupindi
Journal: The Lancet Global Health (2014)

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 affected1WHOGlobal tuberculosis control: WHO report 2013. World Health Organization, Geneva2013Google Scholar and a large market at the base-of-the-pyramid remains unserved. A complete and patient-centric solution will not only include care that meets the International Standards for Tuberculosis Care,2TB CARE IInternational standards for tuberculosis care. 3rd edn. TB CARE I, The Hague2014http://istcweb.org/Google Scholar 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, recognise their clinical and psychosocial needs, and be cost-effective. 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.1WHOGlobal tuberculosis control: WHO report 2013. World Health Organization, Geneva2013Google Scholar Whether patients in India seek care in the public or the private sector, they struggle to get a complete solution. Although the 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 (MDR-TB) and extensively drug-resistant tuberculosis. Of the estimated 64 000 cases of MDR-TB in 2012, only 17 373 cases were diagnosed under the RNTCP.1WHOGlobal tuberculosis control: WHO report 2013. World Health Organization, Geneva2013Google Scholar The diagnostic infrastructure in the public sector relies mainly 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. Recognising these problems, the RNTCP is actively scaling up capacity to diagnose and treat MDR-TB.3Sachdeva KS Kumar A Dewan P Kumar A Satyanarayana S New vision for Revised National Tuberculosis Control Programme (RNTCP): universal access—"reaching the un-reached".Ind J Med Res. 2012; 135: 690-694PubMed Google Scholar 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,4Hazarika I Role of private sector in providing tuberculosis care: evidence from a population-based survey in India.J Glob Infect Dis. 2011; 3: 19-24Crossref PubMed Scopus (38) Google Scholar where the quality of tuberculosis care is suboptimal with inaccurate diagnosis,5Jarosawlski S Pai M Why are inaccurate tuberculosis serological tests widely used in the Indian private healthcare sector? A root-cause analysis.J Epidemiol Glob Health. 2012; 2: 39-50Summary Full Text Full Text PDF PubMed Scopus (54) Google Scholar non-standard drug prescriptions,6Udwadia ZF Pinto LM Uplekar MW Tuberculosis management by private practitioners in Mumbai, India: has anything changed in two decades?.PLoS One. 2010; 5: e12023Crossref PubMed Scopus (161) Google Scholar and limited effort to ensure treatment adherence.7Achanta S Jaju J Kumar A et al.Tuberculosis management practices by Private Practitioners in Andhra Pradesh, India.PLoS One. 2013; 13: e71119Crossref Scopus (33) Google Scholar Also, private practitioners often do not screen for drug resistance and empirical antibiotic abuse is rampant.8Udwadia ZF MDR, XDR, TDR tuberculosis: ominous progression.Thorax. 2012; 67: 286-288Crossref PubMed Scopus (78) Google Scholar All this means that drug resistance can emerge or worsen, with poor outcomes.8Udwadia ZF MDR, XDR, TDR tuberculosis: ominous progression.Thorax. 2012; 67: 286-288Crossref PubMed Scopus (78) Google Scholar Lastly, out-of-pocket expenditure in the private sector can be catastrophic.9Tanimura T Jaramillo E Weil D Raviglione M Lonnroth K Financial burden for tuberculosis patients in low- and middle-income countries: a systematic review.Eur Respir J. 2014; (published online Feb 20.)http://dx.doi.org/10.1183/09031936.00193413PubMed Google Scholar Are there examples of initiatives that address the above systemic problems? Operation ASHA is a non-governmental organisation that extends the RNTCP model, and uses public sector diagnostics and drugs to orchestrate a solution by establishing community-based treatment centres and ensuring adherence using local community providers and partners.10Anupindi R Operation ASHA: effective, efficient, and scalable model for tuberculosis treatment. Ann Arbour: University of Michigan, William Davidson Institute/GlobaLens Publishing.http://globalens.com/casedetail.aspx?cid=1429339Google Scholar 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. World Health Partners 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.11[email protected] . World Health Partners: leveraging entrepreneurship for health care delivery. http://knowledge.wharton.upenn.edu/article/world-health-partners-leveraging-entrepreneurship-health-care-delivery/#. (accessed Feb 28, 2014).Google Scholar The Initiative for Promoting Affordable, Quality TB tests (IPAQT), a coalition of more than 60 private laboratories, supported by non-profits such as the Clinton Health Access Initiative, has increased the availability and affordability of WHO-endorsed tuberculosis tests.12Pai M Promoting affordable and quality tuberculosis testing in India.J Lab Phys. 2013; 5: 1-4Crossref PubMed Google Scholar Although IPAQT is addressing the problem of suboptimal diagnosis, it does not cover treatment. 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.3Sachdeva KS Kumar A Dewan P Kumar A Satyanarayana S New vision for Revised National Tuberculosis Control Programme (RNTCP): universal access—"reaching the un-reached".Ind J Med Res. 2012; 135: 690-694PubMed Google Scholar Recognising the need to leverage the private sector in developing a solution, the plan includes engagement of the private sector using "public private interface agencies" to enlist, sensitise, incentivise, and monitor diagnosis and treatment by private providers, to provide patients' cost offsets such as subsidised diagnostics and free drugs to privately treated patients, and improve case notifications to the RNTCP. Ongoing pilot projects in Mumbai and Patna should inform policies for refinements and scale-up of this model. Outside of India, Operation ASHA is now replicating its model in Cambodia. In Bangladesh, BRAC's tuberculosis programme with shasthya shebikas has been successful in the public sector.13BRAC Health ProgramMaking tuberculosis history: community-based solutions for millions. University Press, Dhaka2011Google Scholar This model is now creating linkages with private providers. Additionally, they have created partnerships with garment industry owners in export processing zones that provide factory workers with better access to tuberculosis diagnosis and treatment using BRAC's infrastructure. With donor support, Interactive Research and Development and partners are expanding access to Xpert MTB/RIF (Cepheid Inc, CA, USA), 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.14Khan AJ Social enterprise models for lung health and diabetes screening and management in 3 Asian megacities.http://www.who.int/tb/careproviders/ppm/Aamir_Khan.pdfGoogle Scholar This model includes management of comorbid conditions such as diabetes and chronic obstructive pulmonary disease, to generate revenue for this social enterprise. 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 crucial. 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, incentivisation, and performance management. Information and communications technologies will also be crucial for success. Solution-centric approaches have shown promise in several other base-of-the-pyramid contexts, from affordable eye care to artificial limbs.15Prahalad CK The fortune at the bottom of the pyramid, 5th anniversary edition. Pearson Prentice Hall, Upper Saddle River2009Google Scholar By using product and process innovations, often with community champions, these models have shown that it is possible to serve base-of-the-pyramid market needs effectively and efficiently and with compassion and dignity. Individuals with tuberculosis deserve nothing less. MP serves on the editorial board of The Lancet Infectious Diseases. He serves as a consultant to the Bill & Melinda Gates Foundation (which did not fund or sponsor this work). We declare that we have no competing interests. The need to further augment the public health system to control tuberculosisWe completely agree with Madhukar Pai and colleagues1 that a complete and patient-centric solution to tuberculosis control should be delivered with dignity and compassion. India's Revised National Tuberculosis Control Programme (RNTCP), which was recognised as one of the best-run tuberculosis control programmes in the world, has only been able to provide 27% of patients with multidrug-resistant tuberculosis with treatment, which is worrisome. Pai and colleagues vouch for patient-centric solutions for complete treatment. Full-Text PDF Open AccessThe need to furtheraugment the public health system to control tuberculosis – Authors' replyWe appreciate the response by Sharath Nagaraja and Ritesh Menezes to our Comment,1 in which we had argued that patients with tuberculosis deserve a complete and patient-centric solution, irrespective of whether they seek care in the public or private health sector. Nagaraja and Menezes seem to have missed this key point and instead reframe the argument as public sector strengthening versus private sector engagement. They also make the erroneous claim that most of India's population is served by the public health system, when data suggest the converse. Full-Text PDF Open Access