In 2013, tuberculosis (TB) claimed an estimated 1.1 million HIV-negative lives and 0.36 million HIV positive lives [1]. While the TB incidence rate has fallen by approximately 45 percent from 1990 to 2013, about 95 percent of all deaths occur in the developing world and 26 percent of global TB cases are in India [1–3]. It is estimated that TB claims almost 300,000 lives per year in India [4].
The World Health Organization recommended first line treatment for TB is the directly observed treatment, short-course (DOTS), a six-month drug therapy at the cost of approximately US$25. It has been championed by the Revised National Tuberculosis Control Programme (RNTCP), the national TB control policy of India. According to official reports, the TB-DOTS strategy of RNTCP achieved a universal coverage in India starting in 2006. A year later, the program also reached a detection rate of 70% of new TB cases (in accordance with the global target) and treatment success rate of 85% [5]. It is estimated that RNTCP saved 1.3 million lives during 1997-2006, at the rate of US$26 per disability adjusted life years (DALYs) gained [6]. The economic return of the program was US$115 per dollar spent.
However, there are still large disparities in the TB program’s coverage across regions of India. In some districts, less than half of the TB cases are being detected [7]. Furthermore, there has been a rapid growth in the number of multi-drug resistant TB (MDR-TB) cases in India during recent years [4,8]. Multi-drug resistant TB (MDR-TB) requires a longer treatment time frame and second line drugs that can cost up to 100 times the cost of first-line drugs. If patients don’t complete or take their treatment for MDR-TB, they can contract extensively drug resistant TB (XDR-TB), which is nearly untreatable [8]. There has been some recent reports of emerging XDR-TB cases in India [9].
In 2013, the Bill and Melinda Gates Foundation launched the Public Private Interface Agency (PPIA) through World Health Partners (WHP) in three Indian cities: Patna, Mehsana, and Mumbai. The PPIA is a pilot intervention to improve TB diagnostics and treatment by targeting referral linkages between various  providers. Providers include formal providers such as specialized doctors, chemists, and laboratories as well as informal providers such as AYUSH (Ayurveda, Yoga and Naturopathy, Unani, Siddha and Homoeopathy) doctors. In 2014, researchers from CDDEP and the Public Health Foundation of India partnered with the Imperial College in London ((Dr. Nimalan Arinaminpathy) to evaluate the health and economic benefits of the PPIA. The research involves building a TB transmission dynamics model that simulates a suspected TB patient’s outcome through the stages of diagnosis and treatment. Using data on intervention cost and out-of-pocket medical expenditure of patients before and after the intervention, the model will also estimate the cost-effectiveness of the intervention and its impact on TB-induced poverty.
The PPIA seeks to improve diagnostics and treatment of TB in urban populations by creating a network of providers that refer patients to obtain free tests (sputum smear microscopy and chest x-rays) and first-line drugs for TB using pre-paid vouchers. WHP trains formal providers on how to correctly diagnose and treat patients using the World Health Organization’s TB Treatment Guidelines. Informal providers are encouraged to refer potential suspects to formal providers for diagnosis. With every confirmed TB case, a provider receives a monetary incentive from WHP, to increase the likelihood of improved provider diagnosis. World Health Partners engages its providers by having them sign an agreement under which they can refer suspects for TB tests and free treatment up to 30 days.
All providers can refer TB suspects for testing to WHP, which runs a call center that assigns unique patient IDs to each patient that opts to receive free tests or drug treatment through the PPIA. The call center tracks patient lab tests and treatment. At least 70% of patients are followed up with through adherence calls, and if these fail, patients are paid house visits to encourage them to adhere to their treatment.
Since January 2015, providers have started referring all patients for GeneXpert tests at a highly subsidized cost of INR 300 (US$5; approximately 15% of the normal cost). Unlike sputum smear microscopy or chest x-rays, GeneXpert is a 90-minute automated diagnostic test that identifies TB positive patients and determines their resistance to first-line drugs. The test allows for faster diagnosis of patients with MDR-TB so that they can start treatment using second-line drugs, which are freely available in the public sector.
Today, on World TB Day, we recognize The Gates Foundation and WHP’s work, which demonstrates a shared commitment to stopping TB in India by improving treatment and early detection of TB.
Aditi Nigam is a CDDEP Senior Research Analyst and Arindam Nandi is a CDDEP Fellow. 
Image courtesy Wikimedia Commons.
References
1     World Health Organization. How many TB cases and deaths are there? Situation 2013. World Health Organization. 2015.http://www.who.int/gho/tb/epidemic/cases_deaths/en/ (accessed 20 Mar2015).
2     World Health Organization. Tuberculosis Fact Sheet No 104. World Health Organization. 2015.http://www.who.int/mediacentre/factsheets/fs104/en/ (accessed 20 Mar2015).
3     World Health Organization Regional Office for South-East Asia. Tuberculosis control in the South-East Asia Region Annual TB Report 2014. 2014.
4     World Health Organizaiton. India: Tuberculosis Profile. In: Global Tuberculosis Report 2012. World Health Organisation 2012. 114.http://who.int/tb/publications/global_report/en/index.html
5     GoI. TB India 2013: Revised National TB Control Programme Annual Status Report. 2013.
6     Goodchild M, Sahu S, Wares F, et al. A cost-benefit analysis of scaling up tuberculosis control in India. The international journal of tuberculosis and lung disease 2011;15:358–62.http://www.ncbi.nlm.nih.gov/pubmed/21333103
7     Satyanarayana S, Nair SA, Chadha SS, et al. From where are tuberculosis patients accessing treatment in India? Results from a cross-sectional community based survey of 30 districts. PloS one 2011;6:e24160.http://dx.plos.org/10.1371/journal.pone.0024160 (accessed 6 Apr2013).
8     Stop TB Partnership World Health Organization. No more crying, no more dying. Towards zero TB deaths in children. 2012.
9     Michael JS, John TJ. Extensively drug-resistant tuberculosis in India: a review. The Indian journal of medical research 2012;136:599–604.http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=3516027&tool=pmcentrez&rendertype=abstract (accessed 23 Mar2015).