End TB In India To Boost Its Health Diplomacy Profile

• 09 Nov 2018

(This editorial is based on the article “End TB in India to boost its health diplomacy profile” which appears in The Livemint on 9th November 2018.)

“It was enough for a nation to look after itself. Today it is no longer sufficient.” This statement is particularly true in the health arena. There is an increasing range of health issues that transcend national boundaries and require action on the global forces that determine the health of people.

The broad political, social and economic implications of health issues have brought more diplomats into the health arena and more public health experts into the world of diplomacy. In today’s interconnected world, a nation’s health is no longer an internal matter, health has recently found its way into diplomacy and foreign policy.

The term “global health diplomacy” aims to capture these multi-level and multi-actor negotiation processes that shape and manage the global policy environment for health. Global health diplomacy is at the frontline of global health governance — this is where the compromises are found and the agreements are reached, in multilateral venues, new alliances and in bilateral agreements.

India and Health Diplomacy

• Health is one of the guiding principles of foreign policy because it has become integral to three global agendas:
  • Security — driven by the fear of the intentional spread of pathogens and an increase in humanitarian conflicts, natural disasters, and emergencies;
  • Economic — concerned not only with the economic effect of poor health on development or of pandemic outbreaks on the global marketplace but also the gain from the growing global market in health goods and services;
  • Social justice — reinforcing health as a social value and human right, supporting the United Nations millennium development goals, advocating for access to medicines and primary health care, and calling for high income countries to invest in a broad range of global health initiatives.
• Being a recent arena of diplomacy, Indian diplomats and foreign policy practitioners have started growing an understanding and developing India’s diplomatic initiatives in the health sector.
• India, has added diplomats to the staff of international health departments. Their common challenge is to navigate a complex system in which issues in domestic and foreign policy intertwine the lines of power and constantly influence change, and where increasingly rapid decisions and skillful negotiations are required in the face of outbreaks of disease, security threats or other issues.
• India has started playing an integral role in global health assistance, making it an integral part of India’s foreign assistance program and its significance is growing exponentially over the years. Indian policymakers believe the scope of the country’s health assistance program will continue to expand and hopeful of exploring opportunities for country’s private health sector and civil society in health assistance initiatives.
• Health assistance can be traced through infrastructure, human resources, education and capacity building. Health assistance can typically be seen in the form of bilateral health assistance, Health IT and Pharma etc. Since 2009, India has committed at least US$100 million to bilateral health projects in nearly 20 countries in south Asia, southeast Asia and Africa.
• This year, for the first time, Indian clinician-cum-TB activist inducted into WHO’s top management team.
• Eradicating TB will factor heavily into India’s image and influencing power in global health diplomacy networks.

TB is airborne. With approximately 300 TB patients per 100,000 Indians, the very process of breathing puts one at risk of acquiring the disease in lungs, spine, brain or any other organ.

The Indian government has also demonstrated political will to improve the health security of citizens with two announcements this year.

First, an aggressive resolve to end tuberculosis (TB) by 2025, 10 years ahead of the World Health Organization’s (WHO’s) goal; and

Second, a step towards achieving universal health care through the Pradhan Mantri Jan Arogya Yojana (PMJAY), promoted as the world’s largest government-sponsored health insurance scheme.

Issues Involved

• India’s run up to the 2025 deadline requires TB transmission to decline at the rate of 15-20% annually. At present, that seems to be a difficult task.
• Even though tests and treatment are available for free across all public health centres, and patients can claim a nutritional incentive of ₹500 per month until fully cured, the current decline rate of TB in India is a worrying 1-2%.
• Early symptoms of TB are non-specific, and quite similar to more commonly occurring conditions, such as secondary infections resulting from seasonal flu. Private practitioners rule out other ailments through antibiotic treatment before ordering TB tests. Delayed TB diagnosis is the biggest risk factor for transmission.
• Half of the estimated patients are either unaware that they have TB, or are unreported in the government’s e-registry for TB, Nikshay.
• Infected patients infect others in the community while undiagnosed. TB transmission can’t be ended until they are cured.
• Non-specific antibiotic courses, multiply the risk manifold, causing the infection to become antibiotic-resistant.
• Another widely prevalent behaviour in the private sector is hesitation to notify and refer their TB patients to public health facilities, despite cash incentives.
• Fear of permanently losing clients and revenue to the public sector is the biggest reason for non-compliance in private sector.

Way Forward

• The government’s long-standing Revised National TB Control Programme (RNTCP) has now initiated an active case-finding campaign in selected population segments—those who are socially, clinically or occupationally more vulnerable than others; that is, living or working in shanty towns, prisons, red-light districts and shelter homes, or AIDS patients.
  • The first three phases of this screening identified more than 12,000 new patients who might have remained hidden otherwise. In the rest of the population, the hope is that TB cases will be duly reported and treated.
• About 50-55% of private practitioners are doctors-by-experience, not degree. This is where the search-and-treat strategy for TB is falling through the cracks. So, fake practitioners should be evicted from medical practices.
• New engagement model of public-private partnership is being tested in Mumbai and Patna, wherein private practitioners are encouraged to manage patients themselves, provided they complete e-Nikshay case notification and follow the standard of care treatment protocol.
• Roadmap towards ending childhood TB should be prepared and it should be the primary focus.
• Though additional budget consideration may pose an uncomfortable challenge for the government, it is unquestionably a fair price to pay for attaining leadership in global health diplomacy. In addition to new provider-focussed strategies, it is time to galvanise the society to drop the fear of stigma, and insist on a TB test, if one’s cough persists for weeks.
• Eradicating polio was an important step; becoming the first nation to eradicate TB will be a giant leap for India.

More facts on TB