A call to make Chennai TB Free

Managing public health in cities present a set of unique challenges as well as opportunities and has led to the emergence of the ‘healthy city’ concept. Cities, as focus areas for health interventions can transform the health landscape with committed political commitment, a distinct population to work with and the opportunities for several stakeholders to come together. This is especially true when it comes to managing TB in cities. 

The risk of transmission of TB is higher with overcrowding, poor ventilation and exposure to indoor and outdoor pollution. Further, the inflow of migrant populations increases the burden on cities.  

Access to healthcare though easier in terms of proximity is challenged by the presence of diverse health care providers. The local health authorities and the State health system provide free TB care under the Revised National Tuberculosis Control Programme (RNTCP). 

The private sector landscape ranges from community pharmacies, AYUSH practitioners, GPs to the larger corporate hospitals. There are challenges in aligning these providers to enable patients to receive standardised high quality and low cost care. In addition, it is well-established that more than 60 per cent of patients access the private sector as the first point of care and often move between these diverse providers. This often delays diagnosis and results in worse outcomes. 

Chennai has an estimated 17,000 cases of tuberculosis, with only 9,000 being notified to the government. It is assumed that the remaining seek care in the private sector but there is not much information on the standards and treatment outcomes. As every untreated patient contributes to the continuous transmission of TB in the community it is imperative to not only identify and accurately treat all individuals with symptoms of TB but also examine their  close contacts and offer preventive therapy for children under 6 years.  

The Government of India’s commitment to end TB by 2025 and create a TB free India has generated new energy and political commitment to accelerate towards ending TB in India which has the largest number of unaccounted cases according to WHO estimates, “the missing million”. 

The new national strategic plan from 2017 to 2025 envisages roll out of free drugs and diagnostics to all TB patients and a special focus on private sector engagement with a multi stakeholder approach. In the future, all patients would have access to a rapid, molecularbased diagnostic test to detect drug resistance, free daily treatment and incentives to improve adherence. This presents a great opportunity for city based initiatives to scale up their interventions and move towards TB-free cities. 

The Corporation of Chennai in partnership with the National Institute for Research in TB (ICMR) and REACH, a Chennai based NGO, has spearheaded the TB Free Chennai Initiative in mission mode to align with national goals. 

The basic objective is to provide standardised TB care in accordance with the Indian Standards of TB care in public and private systems, providing early accurate diagnosis and treatment support to ensure that every patient put on treatment will have successful outcomes with the overall cure rate of 90 per cent. The Corporation will strengthen its program under RNTCP by integrating TB care into all its urban primary health care services, active case finding and creating sustainable and strong linkages with private providers. NIRT will bring a strong evidence based approach to inform both the strategic framework development and monitoring of the initiative to demonstrate impact and provide a model for other urban sites in Tamil Nadu and nationally. 

As a Private Provider Interface Agency (PPIA), REACH will engage private health care providers to promote  quality standards, increase notification and provide treatment support to patients in the private sector. 

Providing access to free services alone will not solve the problem. Patients face innumerable difficulties in completing the long treatment course of 6 to 8 months. Patients who are too sick to work incur loss of livelihood. Even in urban settings stigma and discrimination are rampant. Poor nutrition and co morbidities such as HIV and diabetes as well as managing adverse drug reactions are all predictors for poor outcomes in treatment.

Therefore, to achieve the  vision of a TB Free Chennai a comprehensive approach is needed  to address these other needs. 

Social support systems need to be in place and the corporate sector has a key role to play in helping address strategic and resource needs which public programs may not be able to provide. Community participation, strengthening and capacity building for patients to advocate for their right to care will lead to a push from the community for accountability towards quality care. The initiative will initially be supported by USAID and the Stop TB partnership with technical assistance from Catholic Health Association of India (CHAI). In order to sustain this expanded program, resource commitments will be needed from the State and Chennai City, as well  as from the private sector to develop business models to sustain engagement of private providers and institutionalize support systems for patients.  

TB is a curable disease. And yet, over 1300 people die every year in India from TB. We can do our bit to help identify patients in the community who may be suffering from the disease, and ensure that they are diagnosed and treated. 

Awareness is important, which can be raised by discussing the subject openly.  Schools and colleges can play an important role as we could have an army of well informed volunteers going out into the community. Everybody can contribute by innovative ideas and solutions. Chennai Corporation is looking for partners for this important and ambitious initiative!