The last fortnight saw a lot of high level activity on health care. April 7 was World Health Day, which has the theme of Universal Health Coverage: Everyone, Everywhere. A couple of weeks earlier, on March 24, which is observed as World TB Day, India set itself an extremely ambitious goal. Prime Minister Narendra Modi announced that by 2025, not as far off as you may think, India will completely eradicate TB (“Zero deaths, disease and poverty due to TB”).
An ambitious target
This is a challenging target for a country that is home to the world’s largest number of TB patients in the world. Consider the facts: The disease kills an estimated 4.8 lakh Indians every year, or 1,400 every day. India adds the most number of TB patients every year — 2.9 million, or 27% of the world’s total. Worse, it is also home to the largest number of TB patients who are resistant to multiple drugs commonly used to treat the disease. India has a quarter of the world’s close to half a million multidrug resistant TB (MDR-TB) patients. According to the Global TB Report of 2017, treatment success rate among MDR-TB patients in India is about 46% and the death rate is around 20%.
What does it mean to achieve the goal of a TB-free India by 2025? For starters, India needs to achieve a ten-fold increase in the reduction rate of TB every year, from the current baseline of 217 per 100,000 population (in 2015) to 44 per 100,000 population in less than a decade. According to the National Strategic Plan (NSP) for TB elimination, released last year, this will also involve reducing the mortality rate due to TB from the current 32 per lakh population to just three.
Sounds ambitious? Chew on more facts. According to data in the NSP, this will require upping the number of patients actually notified as TB patients from the current 1.7 million to 3.6 million within the next three years. That may not sound difficult but the NSP report says that the proportion of identified “targeted key affected population” undergoing “active case finding” needs to be 100%. In 2015, this was zero. Targeted key affected population means health workers actively go and test those identified as vulnerable to TB — the poor, the malnourished and those resident in areas where TB is endemic. In other words, nobody was earlier going out and actively trying to find who has TB. Can India’s creaky health care system, even with global funding and support, take this number from zero to 100% in five years?
Challenges ahead
One of the key problems in tackling TB lies in ensuring that patients, once identified, actually take the prescribed course of medication. To its credit, India does back the TB programme. Medicines are not really a problem, and are provided free to patients. But the course of treatment is long: typically six months to a year. India largely follows the WHO-prescribed DOTS system (Directly Observed Treatment, Short-Course) to deal with this problem. This means that the patient will have to come to the treatment centre for medicines, which will have to be taken in the presence of a health worker and certified.
This sounds good on paper and does work to some extent (which is why India’s success rate is higher than the global average) but there are problems. For the poor, a trek to the health centre usually means loss of wages. And if the patient cannot make it due to travel, marriage, or livelihood commitments, the treatment is missed, leading to higher drug resistance and a more persistent problem to solve.
Technological solutions
This is where technology can help. Global software giant Microsoft, for instance, has developed a programme called 99DOTS. In this, each dose is placed in an individual blister pack. Once the patient opens the pack and takes out the pill, a telephone number is seen. All she has to do is give a missed call to that number to log that she has taken the drug. Since the number is visible only after the drug is taken out, there is a high chance that the patient has actually taken the dose. Missed doses trigger SMS alerts and phone counselling by health workers.
Delhi-based ZMQ Development, a technology-based social enterprise which was recognised last month as The Hindu BusinessLine ’s Change Maker of the Year in Digital Transformation, has come up with an even more foolproof solution. It uses the Video Observed Therapy approach. Patients shoot a selfie video while taking the dose at home with the smartphone provided by ZMQ and upload it. This gives a visual confirmation that the drug is taken. Missed doses trigger alerts and interventions by pre-identified support volunteers in the community.
ZMQ calls this the Active Compliance System. What both Microsoft’s and ZMQ’s systems do, however, is something much more important — put the patient at the centre of the treatment, freeing them from the need to supplicate babudom . This is the kind of mindset change that is needed if India is to achieve its ambitious health goals.
