Editorial 1: The need for universal and equitable health coverage

Context

Integrating TB services into the wider public health system is essential for India's goal of achieving equitable and universal health coverage.

Introduction

India has made significant progress in fighting Tuberculosis (TB) by adopting new methods for detection, treatment, and prevention. Key improvements include expanding molecular testing for faster TB and drug-resistance diagnosis, introducing the shorter all-oral BPaLM treatment (a mix of four medicines: Bedaquiline, Pretomanid, Linezolid, and Moxifloxacin), increasing nutrition support under the Ni-kshay Poshan Yojana to ₹1,000 per month, rolling out preventive TB therapy, and involving TB survivors and community champions. These efforts have led to a 17.7% drop in TB cases, from 237 per 1,00,000 people in 2015 to 195 per 1,00,000 in 2023, along with a 21.4% decline in TB-related deaths.

• Since independence, India’s public health system has relied on vertical health programs for disease control, such as the National Tuberculosis Elimination Programme (NTEP).
• This vertical approach has enabled focused efforts and brought significant benefits.
• However, it has also created certain limitations in the healthcare system.
• Integrating TB services into the broader public health system is crucial.
• Such integration is key to achieving equitable and universal health coverage (UHC) in India.

Decentralising TB care for all

Ayushman Bharat and TB Integration

• Launch & Objective: The Ayushman Bharat National Health Protection Scheme was launched in 2018 to ensure universal health coverage (UHC) for the Indian population.
• TB Integration in Ayushman Bharat: TB services have been integrated into both key components of Ayushman Bharat:
  • • Pradhan Mantri Jan Arogya Yojana (AB-PMJAY) – The world’s largest insurance scheme.
    • Ayushman Arogya Mandirs (AAMs) – Formerly known as Health and Wellness Centres, providing comprehensive primary healthcare in rural and urban areas.

TB Services at Ayushman Arogya Mandirs (AAMs)

Challenges in TB Care & Private Sector Involvement

• Preference for Private Sector: Despite free TB services in public healthcare, over 50% of TB patients seek care in the private sector.
• Concerns in Private Healthcare: Uneven care standards lead to delayed diagnosis and poor treatment outcomes.
  • High out-of-pocket expenditure (OOPE) burdens families.
• Solutions & Recommendations: Strengthening referrals from private to public healthcare for cost-effective treatment.
  • Ensuring AB-PMJAY covers full insurance for TB treatment in both public and private sectors.
  • Prioritizing coverage for severely ill patients who may face financial difficulties.

The Road to Equitable TB Care: Five Key Steps

1. Strengthening Person-Centered Care at Scale

• Decentralization & Care Accessibility:
  • While decentralizing TB care, we must ensure person-centered approaches are delivered at scale.
• Model Interventions:
  • Several states have implemented initiatives linking socially and clinically vulnerable TB patients to care.
  • Tamil Nadu’s TN-KET (TB death-free project) successfully reduced TB mortality by identifying high-risk patients and ensuring timely referrals for hospitalization.
  • Other initiatives focus on tribal communities, migrants, and homeless populations.
• Enhancing Public Health Utilization:
  • Strengthening human resources, medical supplies, and infrastructure will drive UHC and improve TB care.

2. Recognizing Intersectionalities in TB Care

• National TB Elimination Programme (NTEP) Approach:
  • The gender-responsive TB framework acknowledges diverse TB experiences.
  • Improving gender and disability understanding will challenge norms but is essential for equitable care.

3. Ensuring Integrated TB & General Healthcare Services

• Objective:
  • Adopt multi-disease screening models in community healthcare settings for early detection and treatment.

4. Minimizing Out-of-Pocket Expenditure (OOPE) & Expanding Social Protection

• Existing Initiatives:
  • Nikshay Poshan Yojana (NPY) provides monetary support for nutrition.
  • ‘100 Days’ case-finding campaign helps detect TB early and reduce pre-diagnosis costs.

5. Lessons from COVID-19, communication

• Equal access to information and knowledge is crucial in addressing TB effectively.
• TB continues to be widely misunderstood, requiring targeted awareness efforts.
• The swift public understanding of COVID-19 was achieved through extensive, science-based communication across various platforms.
• A similar multi-platform approach is needed for TB to encourage timely diagnosis, treatment, and preventive measures within households and communities.
• Spreading awareness about drug-resistant TB is essential, especially in the context of rising antimicrobial resistance (AMR).
• Reducing TB-related stigma is vital for promoting early detection and improving treatment success rates.

Conclusion

An equitable TB program ensures that every individual receives high-quality, person-centered care tailored to their specific needs. Equity is fundamental to healthcare and crucial for achieving TB elimination and universal health coverage. India’s TB response is well-positioned to set global standards and benchmarks, and prioritizing equity will further accelerate progress.