Multi drug resistant TB continues to emerge and spread and is posing to be a major public health challenge.
At a call centre in Gurgaon, Haryana, there is an air of urgency. Calls are coming in from private practitioners and chemists in Gujarat. There are patient details to be noted, voucher numbers to be generated. Its all part of an innovative government programme to control TB in Gujarat's Mehsana district.
Over 800 kms away, in Kokas village, Mehsana district, the village pujari is making a slow but steady recovery. 60-year-old Bhagwangiri has multi-drug resistant TB, that has a high mortality rate.
"We call this 'bad TB' in Gujarati. So the usual anti TB medicines will not have any effect on him. His medicines will have to be changed," says Bhrat Sagar, Senior TB Treatment Supervisor at the Mehsana District TB centre.
Multi drug resistant TB which continues to emerge and spread and is posing to be a major public health challenge.
This is Bhagwangiri's second encounter with TB. He was not cured the first time round because he stopped taking his medicines.
"I felt fine so I stopped the medicines. I also stopped going to the doctor," says he.
Last year he developed a severe cough. He visited two private doctors, but they failed to make a correct diagnosis.
According to him, they did not suspect TB. "They would prescribe medicines and take money. And when the cough started again, they would start the medicines again."
Bhagwangiri is typical of patients who do not understand the importance of completing their treatment. 10 years ago, he had got TB but failed to finish his six month course of treatment. Then late last year, he once again got TB and this time a multi-drug resistant form that requires a 24 month course of treatment
Multi drug resistant TB does not respond to two most powerful anti TB drugs. While it can be cured with long treatments of second line drugs, these drugs are a hundred times more expensive.
To control drug-resistant TB, the government has to ensure that every patient gets the right treatment and the treatment is sustained and not interrupted midway.
Take 20 year old Anil who is a daily wage labour and earns about Rs 150 a day.
He got TB and was being treated by a private practitioner. He did not continue because he could not afford the medicines. Anil said, "He charged about Rs 1,600 for his fees and 15 days of medicine."
In Akhaj village, we meet a 35 year old shopkeeper who has HIV co infection with TB, another serious challenge. In 2013, it is estimated that 38,000 people who had both HIV and TB lost their lives.
One out of every four TB patient in the world is in India. And at least half of those are being managed treated by private doctors. To control TB, private doctors have to be helped and supported to be effective.
In August last year the Ministry of Health and Family Welfare and the Central TB Division launched a pilot project in Mehsana to provide free anti TB drugs to patients who go to private health facilities the same way patients who go to government facilities are given. This two year project is funded by the Bill and Melinda Gates Foundation.
But before it did that, it had to resolve an important difference in the approach of Government doctors and private doctors. While government doctors prescribe TB drugs for alternate days, that is an intermittent regimen, private doctors prescribe a daily regimen of TB drugs.
The project decided to support the daily regimen.
Dr Javedahmed A Shaikh, Private practitioner, Mehsana, explains, "We prefer daily therapy particularly if the patient has diabetes, if a patient has got HIV, if a patient has got chronic renal disease, if he is on steroid therapy or if he has got cancer or if the disease is extensive".
Dr Shaikh, a leading doctor in Mehsana with a busy private practice, is part of the pilot project.
The project began with the mapping of private doctors and chemists in the district and holding sensitisation meetings with them. Standard operating procedures and a masterlist of drugs were prepared in consultation with them.
Under the project, whenever a patient is diagnosed with TB, the private doctor contacts a call centre, giving full prescription details and patient profiles. The call centre generates a unique voucher number which is given to the doctor, who writes the number on the prescription.
At the chemist shop, this man is collecting medicines for his mother who has TB.
The chemist calls the call centre. The voucher number on her prescription is validated and the patient is given free drugs for a month at a time.
According to Dr. Harish Patel, a private practitioner in Mehsana, "The patients are happy as the drug is free for them. We call the Delhi call centre. We only have to spend a few minutes on the call. Once the voucher number is generated and then we send the patient to the pharmacy."
Once the drugs are provided, the call centre contacts the patient for confirmation of receipt of free medicine.
One of the pilot project's biggest successes is the fact that it engages with private practitioners effectively to control TB. Nearly 50% of the private practitioners who treat TB patients are already linked to the projects and those who have come on board have stayed.
Thakur Prahlad Chand Virjee, a TB patient, tells us that he went to a private doctor because he was afraid of the long queues at a government hospital. He could not take a day off from work.
"I went to the doctor when I started spitting blood. The good thing is I can get my medicines from the neighbourhood chemist and its free. There has not been any difficulty so far. Supervisor from the government's TB centre have been to my home. Now I even get messages on my phone", says he.
Adds Dr Shaikh, "Treatment given by the Government hospitals are equally good but patients have some misconceptions. When we refer them to civil hospital, they don't go. They are lost in the community. If they don't get treatment, they will spread infection. So instead of that we are giving treatment and this treatment is made free of cost by our Government. Patients are also satisfied that they are consulting private doctors."
Eighty chemists are part of the project and they say they find the system efficient.
Khushboo Patel, a chemist in Mehsana, said, " After the patient brings the prescription to us, we call the TB call centre. We get our pharmacy ID checked. They know which chemist is calling them. And then they check the medicines."
Govind Patel of Alsife medical store has been part of the project for 5 months. Three hundred and forty TB patients have been to his store for medicines during this period.
He said," Patients will benefit, that too those who are poor. Earlier many were not completing their treatment because of the cost of the medicines. Since the medicine is free now, they take the complete dosage.The Government is giving us an extra 3 per cent on the cost of the medicine. That is an added benefit for us."
Chemists are selling more drugs because now TB patients are completing their course of treatment. They are also deriving satisfaction from the fact that they are now a part of an important initiative. Till now the scheme has covered over 1400 privately diagnosed TB patients.
The district TB centre is notified of these patients through an online system used by the call centre.
Three years ago it was made mandatory for all healthcare providers to report every TB case to the local health authorities. One TB patient can infect 10 more and it is vital to making India TB free.
However, a majority of cases are not being notified. "We don't have any such instructions as such. If we receive any such instruction then we will definitely notify them. I have never notified," says a physician in Delhi.
It is believed that across the country nearly 10 lakh privately diagnosed TB patients are not notified.
The government is unable to gather data for planning at the national and state levels. It is also unable to monitor the treatment of these patients, to ensure there is no inappropriate or incorrect use of drugs.
Dr. Niraj Kulshreshtha, who is additional deputy director general, Central TB Division, said" We have advertised in newspapers. We have given it out on radio, TV and everything. We have a web based system, and there is provision of ID and password for all practitioners. They can just contact their district officer for a password and ID so that they can directly enter the cases into the system. However, I fully agree that the response was very little because we were dependent on the hard copy and everything. Now, in the last I think in a few months, I should say, the number has increased from a few thousand to lakhs. Now, at this moment we have got almost 1.2 lakhs from the private sector only."
In Mehsana, the information on TB cases is used for public health action by the district TB centre. Treatment supervisors make home visits to explain in detail the implications of the disease and precautions to be taken. If necessary, preventive medicines are given to family members. Follow up visits are made to check on treatment adherence. Efforts are taken at the level of community health centres as well as primary health centres like this one.
Jayaben J Panehal, ASHA worker, Akhaj village, said, "I tell the patients to eat green leafy vegetables and pulses and make them understand that they will be fine if they complete their medication."
The district TB officer and the staff have also established a rapport with private doctors which is striking and hopeful since there is a divide between government and private doctors in most parts of the country.
In Kheralu block, it has led to the Manav Kalyan general hospital, which is run by a charitable trust, joining hands with the government.
"Since we know that most of the patients belong to the lower middle class, we decided to not take the consultation fee of Rs 30. We have also ensured that the patients do not have to pay anything for the X-rays that are a part of the diagnosis. If the sputum is needed, then we send them to the nearest TB hospital. We have made an entire list for all patients to call them after 30 days. Both our staff and the government staff go there. There is a coordination between the two," says Sundeep Rawal, trustee at the Manav Kalyan General Hospital.
Agrees Dr Ravi Patel, medical officer at the Manav Kalyan General Hospital, ,"This is a joint effort. The government alone cannot eradicate TB. A scheme like this requires help from both side."
The pilot project will provide a better estimation of the disease burden. However, there needs to be greater emphasis on achieving patients' adherence to treatment. It has to be about helping the patients.
There is also no component to ensure early detection of cases. One way is through mass awareness campaigns. Pictorial and verbal messages in local languages are necessary.
Dr. Niraj Kulshreshtha said, "As far as mass awareness is concerned, do you know how expensive media buying is today. We have a campaign of Rs 3 crore for 15 days only. How many campaigns can we afford to do from domestic budgeting? Partners should come forward."
Currently there are similar projects in Patna and Mumbai. If all states and districts are involved, the project can help reduce the number of new TB cases as well as the emergence of multi drug resistant TB. Around 20 lakh new TB cases are detected each year. Though the disease is fully curable with modern anti TB treatment, it kills nearly 2.5 lakh people annually.
In the 8 months since the Mehsana project was launched there has been a visible and positive impact. Clearly, the project has to be taken to the next level and expanded across the country.