I still remember that day in late 2012, when this patient walked into my lab. He must have been in his early forties looking very weak and emaciated. He handed over the prescription and told me that his doctor had asked him to give his blood sample for a TB test. I was taken aback. I told the patient he would need to give his sputum for testing and the test would cost Rs.5500 (US$85). He baulked at the amount. He clearly couldn’t afford the test, which is when I recommended he visit a government hospital for free testing and treatment. He left my lab and I never saw him again.
-Dr. Navin Dang, Director of Dr. Dang’s Lab
This World TB Day, CHAI recognizes that fighting tuberculosis in India is key to eliminating the disease worldwide. Tuberculosis is one of the biggest killers in India, with two people dying every three minutes due to TB. It is estimated that 40 percent of the Indian population has tuberculosis. In fact, in 2016, India accounted for 27 percent of new TB cases and one-third of TB deaths in HIV negative patients, globally.
Too many of these cases go missing – a term used to reflect the millions of people who remain undiagnosed or are diagnosed but choose to be treated at private hospitals or labs, which do not always have the systems in place to report cases back to the public health sector. This has made it difficult for the government to track TB across India and intervene to stop the spread of the disease.
But there has been progress in closing the gap between the public and private health sectors, so no more TB cases go missing. Two initiatives – the first a well-established group of private labs and the second, a newly launched government project – are leading the way toward a TB-free world.
Over half of India prefers to seek treatment in the private sector, despite a strong national TB program, which provides free diagnosis and medication. Patients may choose private clinics based on the perception of greater convenience (closer facilities, shorter waits) or better customer service.
But many people cannot afford to be tested for TB—never mind treated for the disease—in the private sector, says Dr. Navin Dang, director of Dr. Dang’s lab, a leading diagnostic laboratory in New Delhi.
In India, government-run programs provide universal care for TB patients, but in the past, identifying those patients could be difficult. In 2016, only 63 percent of an estimated 2.8 million TB cases were reported across public or private sectors—the private sector accounted for 19 percent of those reports. The significant gap between the number of patients seeking care and the low level of reported cases reflects a high level of underreporting by the private sector. The lack of coordination between the national TB program and private labs means that the quality of care for patients cannot be appropriately ensured.
For example, early in 2012, the Indian government banned blood tests for diagnosing active TB, based on advice from the World Health Organization (WHO) that these tests delivered inconsistent and imprecise results. WHO instead recommended more accurate molecular diagnostic tests, such as GeneXpert. However, these tests were very expensive for private labs to procure. As a result, many doctors were not aware of them and only a few labs offered the tests at very high prices. This meant that because most people sought care in the private sector, they didn’t have access to quality tests and their diagnosis could be delayed or even incorrect. As a result, these patients were at risk of spreading TB, becoming drug resistant, or even dying.
In 2013, in order to close this gap, CHAI helped form the Initiative for Promoting Affordable and Quality TB Tests (IPAQT), a consortium of private labs in India. The group’s goal was to lower the acquisition cost of GeneXpert tests—and they succeeded. IPAQT negotiated a 50 percent reduction in the cost of a test to the consumer.
Dr. Dang’s lab was one of the first to join the consortium.
“This was a win-win for all of us. The patient benefited from up to 50 percent lower test price, at the same time labs like ours could profitably conduct tests,” he says.
Today, more than 200 labs are part of IPAQT. All offer GeneXpert tests at less than $34 compared to the prevailing private sector market rate, which ranges between $47 and $77. Over the past 5 years, close to 700,000 possible TB patients have been tested through IPAQT labs.
“Using a test such as GeneXpert, which gives me a rapid, accurate result, helps me start treatment rapidly, thereby helping the patient, and arresting the spread of the disease to others,” says Dr. Lancelot Pinto, a consultant respirologist at the P.D. Hinduja National Hospital and Medical Research Centre in Mumbai. “Being able to do so without worrying about costs has improved the quality of care offered to my patients.”
Building on the success of IPAQT, India has made private sector engagement a priority in its National Strategic Plan (NSP) 2017-2025 for tuberculosis. The importance of the public and private sector working together to find missing TB cases is reflected in the government’s mantra, “go where the patients go”. CHAI is supporting the ambitious agenda the plan sets out through a Global Fund-supported project called Joint Effort for Elimination of Tuberculosis (JEET).
JEET aims to more closely connect private hospitals, clinics and labs with public health programs in order to facilitate better reporting of TB cases, access to affordable TB diagnostics in the private sector, as well as helping patients to stay on treatment until it is completed, while reducing the cost of that treatment—no matter where someone seeks it.
Both IPAQT and JEET are powerful examples of how innovative public health sector engagement is activating new leaders in the private sector to extend the reach of quality care and expedite efforts toward a TB-free world.
