April 24, 2014

WHO hits back at growing wave of immunisation deniers“Rolling back vaccination undermines global fight against disease”

The World Health Organization hit back on Wednesday against vaccine deniers who claim that immunisation is pointless, risky and that the body is better off fighting disease unaided. "The impact of vaccines on people's lives is truly one of the best things that one could see out there," said Jean-Marie Okwo-Bele, head of the UN health agency's immunisation and vaccines division.

Opposition to routine vaccination of children against contagious diseases such as measles and whooping cough has been on the rise in recent years, notably in the United States and Britain. A hardline minority disputes the necessity of vaccination outright, while doubters focus on fears such as the alleged links between measles vaccines and autism, rejected by the overwhelming majority of scientists.

"We're trying hard to contain and reverse the trend," Okwo-Bele told reporters. "We have a huge proportion of people who believe in vaccines. They need to help us convey the messages," he added. The total or near-complete disappearance of many killer or crippling diseases in rich nations has bred complacency, according to the WHO.

"The important thing about complacency is that the number of susceptible people who resist or reject facts and information will accumulate, and the disease will come back, as you're seeing in the United States with measles and whooping cough, which are terrible diseases," said WHO immunisation expert Tracey Goodman.

"It's a tragedy that could be avoided," she said.

Just because a disease seems long gone, there is no reason to rein in vaccination against it, according to the WHO. "All of this needs sustainability. For polio, it's not because your country has been polio-free for 10 or 15 years that there is no risk, so long as the disease has not been completely wiped out worldwide," said Okwo-Bele.

Rolling back vaccination in some countries also undermines the global fight against disease, the WHO warned.

"When we look at the number of people being vaccinated each year, for childhood vaccination we're seeing close to 85 percent being vaccinated, so this is still really good," Okwo-Bele said, underlining that up to three million lives are saved as a result.

"But each new cohort must be vaccinated. We will reap the full benefits of vaccines only if all individuals in all communities receive the vaccines they need. And clearly this is a shared responsibility," he added.

Developing countries have seen resistance in some areas to vaccination, for example in northern Nigeria and Pakistan where polio immunisation campaigns have been dubbed a foreign conspiracy by local opponents.

And war also takes its toll, with polio rearing its head in Syria, previously free of the disease thanks to widespread immunisation. — AFP

April 24, 2014, Opinion: Editorial

A virus to watch out for

In September 2012, an alert Egyptian doctor working in a Saudi Arabian hospital isolated a new human virus in samples taken from a man who had died of pneumonia and kidney failure. The virus came to be known as the Middle East respiratory syndrome coronavirus (MERS-CoV).

By late last month, 200 laboratory-confirmed cases of people infected by the virus were reported to the World Health Organisation, with 85 deaths. Since then, however, there has been a spurt in infections, with 53 more cases and eight additional deaths being reported to the WHO. The vast majority of all MERS-CoV cases have occurred in the Middle East, with Saudi Arabia accounting for a large proportion of them. The United Arab Emirates, Jordan, Kuwait, Oman, Qatar and Yemen have also reported cases. France, Germany, Italy, the United Kingdom, Tunisia and Greece reported instances where people had been infected in the Middle East or came into contact with such infected individuals. Asia recently reported its first cases — and the first death from the virus. A 54-year-old Malaysian man appears to have caught the virus while on a pilgrimage to Saudi Arabia; he developed pneumonia on his return and died days later. A male nurse from the Philippines, who had been working in the UAE, was found to be carrying the virus though he did not fall sick.

India — especially States like Kerala — needs to be watchful. “Countries that have large numbers of travellers to the region, including workers, are reminded of the need for vigilance in the form of surveillance, and the importance of good infection control practices in managing patients with acute respiratory infections,” the WHO cautioned in an update last month. Unlike the swine-origin flu virus that caused the 2009 pandemic, the MERS virus does not easily spread from one person to another. But it has a high case fatality rate and its appearance here could well fuel public anxiety. That can be avoided if the Central and State governments put in place well thought-out plans for testing and surveillance as well as for dealing with any cases that turn up. Likewise, hospitals, both government-run ones and those in the private sector, need to be ready to handle patients who have the virus.

In the Middle East, many infections have occurred in hospitals, and their staff members have been among those affected. Healthcare facilities dealing with

MERS-CoV infections should take appropriate measures to reduce the risk of the virus passing to other patients, staff and visitors, warns the WHO. Now that the virus has reached Asia, India’s Central and State governments would do well to review their preparedness.

April 18, 2014

Spreading good vibes through ‘Tulasi’

For Seemakurthi Kasi Viswanath of Gandhinagar, handing over home-grown ‘Tulasi’ plants to visitors has become a habit

For 60-year-old pharmacy businessman Seemakurthi Kasi Viswanath of Gandhinagar, a wish-list greets him in every day in the morning. The list does not pertain to finance but for a ‘Lakshmi Tulasi’ or Basil (ocimum tenuiflorium) sapling.And, Mr. Viswanath, without any hesitation, picks up the saplings from the terrace of his three-storey building and hands it over to people, who flock his house with a request for the medicinal plant.

The recipients shower praise on Mr. Viswanath and thank him for giving the sacred plant which is not easily available or sold in nurseries throughout the year.

It’s a regular phenomenon for this elderly businessman for the past five years. At least a dozen people, mostly women, throng the businessman’s house-cum-office at Ramarao Street in Gandhinagar daily requesting him to donate the plant. A vinyl-sheet board displayed in front his house also says anyone can pick up

tulasi plant free-of-cost.

“It’s like a pharmacy businessman spreading herbal message by distributing sacred plants,” says a shopkeeper from the same locality. Women from far off places like Ajithsingh Nagar, Benz Circle, Satyanarayanapuram, Ramalingeswar Nagar, One Town and Rajarajeswaripeta descend on his house to pick up a plant. Some even take 10 plants to distribute among their relatives and friends.

‘Small initiative’“This small initiative gives me immense satisfaction and I will continue it,” Mr. Viswanath says, saying that he spends 15 minutes everyday in the morning to take care of plants on the terrace. The plant will not be distributed on Tuesdays and Fridays as it is considered as inauspicious.

Traditional plantMany Hindus have ‘Tulasi’ plants growing in front of or near their home, often in special pots or small masonry structures. Traditionally, it is planted in the centre of the courtyard of houses. The plant is cultivated for religious and medicinal purposes, he adds.

April 7, 2014, OPINION: EDITORIAL

Neutralising a mass killer

The curiosity and keen observation shown by a single doctor at the All-India Institute of Medical Sciences in New Delhi in 1985, combined with unprecedented team work by people from 13 institutions, both in India and abroad, would soon start annually saving the lives of thousands of children aged less than five years from a mass killer — rotavirus diarrhoea.

In India, the disease annually kills over 100,000 children below the age of one, making the country account for a quarter of all global deaths caused by rotavirus diarrhoea. The majority of instances of the disease caused by the virus occurs during the first two years of age. According to results published recently in The Lancet, a Phase III trial of an indigenously developed rotavirus vaccine 116E carried out in three centres was found to be safe; it had 56.4 per cent efficacy in preventing severe rotavirus gastroenteritis in infants during their first year of life. Though the efficacy of the vaccine is only modest, it is superior to currently available ones. In the case of high-burden countries like India, even the modest efficacy of the vaccine would go a long way in reducing the number of deaths. The efficacy would further shoot up when widespread immunity is achieved through sustained vaccination of a majority of infants. Hence, there is a real possibility of the number of deaths dropping sharply in a few years after the introduction of the vaccine. It can also bring about a major reduction in the number of instances of hospitalisation in those aged below five, within two years of its introduction.

The vaccine, which would be made available to the government at not more than $1 a dose, is expected to be licensed shortly. It is imperative that the government quickly includes it in the national immunisation programme. The fact that three doses can be co-administered with other vaccines during the routine immunisation schedule makes it all the more attractive. While it is true that improving sanitation and hygiene levels is insufficient to rein in rotavirus diarrhoea, there is a compelling need to improve social infrastructure in order to control other pathogen-caused diseases like cholera. Besides the direct benefits from the vaccine, the isolation of the human neo-natal rotavirus strain and the conduct of clinical trials in India have given the science of vaccine development a much-needed boost. Though it has taken nearly 30 years to reach this stage, the development of this vaccine proves that Indian companies can take to

completion clinical trials of novel drug candidates. In fact, the government should adopt the same model to develop drugs for other neglected tropical diseases that primarily affect people living in poverty in the developing countries.

March 27, 2014

WHO officially declares India ‘polio-free’

No polio cases were reported in India for the past three years

The World Health Organisation (WHO) South-East Asia Region, home to a quarter of the world’s population, was certified polio-free on Thursday by an independent commission under the WHO certification process.This is the fourth of six WHO Regions to be certified, marking an important step

towards global polio eradication. With this step, 80 per cent of the world’s population now lives in certified polio-free regions.An independent panel of 11 experts in public health, epidemiology, virology, clinical medicine and related specialties constituting the South-East Asia Regional Certification Commission for Polio Eradication (SEA-RCCPE) met for two days to

review evidence from countries before reaching the decision that all 11 countries of the Region, including India, are now polio-free and have met the requirements for certification.To mark the occasion, the WHO presented official certification to India for its ‘Polio Free’ status. The Minister for Health and Family Welfare, Ghulam Nabi Azad, received the official certificate. Speaking at the function, Mr. Azad expressed happiness at the historic public health achievement which seemed impossible with India having the highest burden of polio cases in the world.Mr. Azad said India embarked on the programme to eradicate the nation of polio 19 years ago in 1995, when the disease used to cripple more than 50,000 children in the country every year. He said this achievement had been possible with resolute will at the highest levels, technological innovations like the indigenous bivalent polio vaccine, adequate domestic financial resources and close monitoring of polio programme, with which immunization levels soared to 99 per cent coverage and India achieved polio eradication. A 2.3-million strong team of polio volunteers and 150,000 supervisors worked day and night to reach every child.“This is a momentous victory for the millions of health workers who have worked with governments, non-governmental organisations, civil society and international partners to eradicate polio from the Region. It is a sign of what we can bequeath our children when we work together,” said Dr. Poonam Khetrapal Singh, Regional Director for the WHO South-East Asia Region.Certification of the Region comes as countries prepare for the introduction of inactivated polio vaccine (IPV) in routine immunization as part of the eventual phasing out of oral polio vaccines (OPV). More than 120 countries currently use only OPV. These countries will introduce a dose of IPV by the end of 2015 as

part of their commitment to the global polio endgame plan which aims to ensure a polio-free world by 2018.

March 26, 2014

A new challenge: introducing injectable polio vaccine

India is among 140 countries that rely on the oral polio vaccine. For India, which has successfully kept naturally-occurring ‘wild’ polioviruses at bay for three whole years, a new challenge looms.India is among 140 countries that rely on the oral polio vaccine (OPV). These countries have now been asked to introduce an injectable inactivated polio vaccine (IPV)

into their routine childhood immunisation programme by the end of next year.The oral vaccine, which is cheap and easily administered, uses live but weakened forms of the poliovirus. But the live vaccine viruses can occasionally revert to virulence. Vaccine-derived viruses can gain the ability to transmit within communities and even pass from one country to another. Such ‘circulating vaccine-derived polioviruses’ (cVDPV) have struck over 700 children since the year 2000, producing outbreaks in several countries, including Pakistan, Afghanistan, Nigeria and Somalia. More than 95 per cent of the cVPDV cases in recent years have been of the type 2 strain (the poliovirus has three strains, types 1, 2 and 3). Polio caused by a wild type 2 virus was, on the other hand, last seen 15 years back.The Global Polio Eradication Initiative (GPEI), which coordinates the global fight again polio, therefore wants to stop all use of OPV that contains the type 2 vaccine strain. Trivalent OPV, with all three types of vaccine strains, is to be replaced by bivalent OPV with only type 1 and type 3 vaccine strains. But before making that switch, the GPEI has asked all countries using trivalent OPV to introduce at least one dose of the injectable IPV vaccine into their routine immunisation programme. IPV, which is more expensive, uses killed forms of the three types of wild viruses and carries no risk of reversion to virulence. This vaccine would provide protection against any type 2 vaccine-derived viruses lingering in the environment. Trials carried out with IPV in Tamil Nadu around the 1980s by veteran virologist T. Jacob John and his colleagues at the Christian Medical College at Vellore had found that the injectable vaccine was very effective against the poliovirus in an Indian context. An independent effort that tested IPV in Mumbai slums came to the same conclusion. If IPV had been introduced in India’s routine immunisation programme and OPV used in mass campaigns, “we could have eliminated polio decades ago,” writes Dr. Jacob John in an article appearing in the Economic & Political Weekly next month. A multi-centre study under way in the country is examining the immunity that would be provided when bivalent OPV and IPV are employed in routine childhood immunisation.But for IPV to be effectively deployed, routine immunisation coverage has to be improved. According to the National Family Health Survey of 2005-06, while over 80 per cent of children in Tamil Nadu had received all basic vaccinations,

only 23 per cent of those in Uttar Pradesh and 33 per cent in Bihar were similarly covered. Lessons from India's success in polio eradication are being used to enhance routine immunisation and reach under-served communities. This includes drawing up comprehensive micro-plans for routine immunisation, intensively training frontline health workers who will carry out vaccinations and putting in place monitoring systems so that corrective measures can be taken when needed.

March 22, 2014, Opinion: Editorial

Road to urban future

The grim future of cities played out in Paris recently. Smog wrapped the city and air pollution increased beyond safe limits. Pollutants, particularly particulate matter measuring less than 10 micrometre in diameter (PM) reached unsafe levels of 180 micrograms per cubic metre, against the WHO’s permissible limit of 50 micrograms per cubic metre (24-hour mean). Though bad weather contributed to this high concentration, the principal cause, as is often the case, was increased fuel emission. The city authorities had to take drastic steps to reduce pollution since prolonged inhaling of particulate matter would cause respiratory diseases, lung cancer and cardiovascular ailments. They imposed restrictions on the use of cars, permitting vehicles with odd and even number plates to ply only on alternate dates and encouraging shared use of cars. People were allowed to use buses, Metro rail and other public transport, besides shared bicycles, free of charge during weekends. The reasoning was that restrictions and incentives would encourage commuters to shift to public transport, thus reducing pollution. Initial reports indicated that these measures worked, and congestion had come down by 60 per cent. Free use of public transport cost the city about $5.5 million a day, but considering the public-health interest it was a necessary investment.

There is a lesson or two here for Indian cities. The Central Pollution Control Board has listed more than 70 cities that have violated ambient air quality standards. Places such as Delhi and Ludhiana have unacceptable levels of PM — 198 and 259 micrograms per cubic metre respectively. Mitigation efforts thus far have been limited to improving the fuel efficiency of vehicles. Enhancing emission norms is necessary, but equally critical is the need to increase the use of public transport. Delhi is a case in point. The Environment Pollution (Prevention and Control) Authority for the Delhi region, in a recent report, stated that all gains made by converting buses and three-wheelers to Compressed Natural Gas have been lost to a rapid increase in the number of private vehicles. The level of particulate matter has increased substantially over the years. Though various urban policies have stated that public transport is a priority, on the ground, investments have not matched intentions. The modal share of public transport has steadily declined in the large cities. It is only in recent years that State governments are trying to increase transport options by

building metro rail networks. This alone may not deliver. Integrating city functions with transport plans and encouraging non-motorised transport such as cycling are also critical. The future of Indian cities is inextricably tied to the improvement of public transport.

March 24, 2014m Opinion: Comment

A million missing patients - Nalini Krishnan

Until activists and patients question approaches to prevention, diagnosis and treatment, TB will continue to plague us

Tuberculosis in India is big: 2.3 million cases, 30,000 deaths, a million missing patients. These terrifying numbers remind us of a continuing crisis — when every TB death is preventable. Behind these numbers are innumerable unheard stories of human

suffering — of misdiagnosis, inappropriate treatment and lack of access to care resulting in chronic illness and death. Why are these stories not heard? Because TB patients remain silent, disenfranchised, and find no platform to voice their issues. And they don’t have champions for their cause.

A complex interplay: Tuberculosis is not just a clinical issue. Its management requires the interplay of clinical medicine, social sciences, factors of equity and right to health. Ironically, this complex interplay is what prevents patients from accessing care early, which is vital to preventing deaths.

The patient-centred approach is supposed to be the hallmark of the DOTS system of delivery under the Revised National TB Control Programme, RNTCP, where the caregiver becomes entirely responsible for ensuring that the patient takes drugs regularly and completes the treatment. However, the programme has not factored in and adequately addressed a critical issue — a patient’s right to choose the provider. Closely linked to this is the issue of confidentiality, given the stigmatisation of TB patients in the community and by health providers themselves. In addition, the public health system has not taken into account the need for social and nutritional support. There are structural issues of delivery as well. TB control services are delivered through a vertical mechanism that is not

integrated into primary health care delivery, which is the first point of care in public health services. This is why despite the RNTCP offering free diagnosis and treatment everywhere, patients prefer private providers.

More than 60 per cent of patients choose a provider from the private sector, most often the point of first contact. But here they have no protection against inaccurate testing or irrational prescriptions. Poor administration of drugs along with irrational prescriptions and unregulated sale of anti-TB drugs fuel the transmission of drug-resistant TB. Yet, the government seems disinclined to regulate the private sector.

The silence around these challenges is deafening. It is disturbing that even with such catastrophic impact, few TB patients and activists are empowered enough to question the quality of preventive and curative services that exist. However, until tough questions are asked both in the public and private sector, TB will continue to plague us.

There is an urgent need for activists and patients to speak up and question approaches to prevention, diagnosis and treatment. We need to question the purely clinical approaches. Within the public health system we also need to demand the inclusion of civil society in the planning and review of the anti-TB programme at the national, State and district levels. However, for all this, patients and activists need funding to build empowered communities.

From the private sector, activists must seek accountability in the areas of diagnosis and treatment. Also, serology-based testing for TB should be banned and mandatory notification of TB cases made compulsory.

There is a need to strengthen community engagement to ensure open participation, empower the patient, family and community with information and knowledge to speak out for their rights and for public health safety.

There are learnings from experiences in the fight against HIV/AIDS. Not only were patients empowered enough to question the credibility of health systems but they were an integral part of decision-making processes.

TB could affect anyone, irrespective of social or economic status as it spreads through the air we breathe. We need opinion leaders, concerned citizens and public figures to become champions in the fight against TB.

As a society and a community we are failing not only these patients but also ourselves by not demanding the rights of patients to high-quality care and management. Until everyone speaks out, and embarks on collective action to

fight TB, India will continue to lose lives, and the missing million will not be accounted for.

(Dr. Nalini Krishnan is the Director of REACH, a non-governmental organisation working for care and support of TB patients in Tamil Nadu. E-mail: nalinikrishnan@gmail.com)

February 9, 2014, Opinion: Open page

The persisting challenge of leprosy eradication

While India celebrates its near-victory over polio, leprosy continues to haunt it.

To commemorate Mahatma Gandhi’s selfless efforts to care for those affected by leprosy, January 30, the day of his martyrdom, is observed as Anti-Leprosy Day.

Leprosy affects close to a quarter million people (2,32,857 new cases in 2012) across the world. About 58 per cent of them are in India, where transmission continues in spite of it being declared as eliminated as a public health problem in 2005. India has the world’s highest burden of the disease: 1,34,752 new cases were detected in 2012-13. On an average, every hour more than 15 new cases are diagnosed here; that adds up to

some 1,34,000 cases a year. These include 13,387 children. Importantly, 4,650 (35 per cent) of these children have presented a visible disability at the time of diagnosis, indicating late or delayed presentation. The next high-burden country is Brazil, with 33,303 cases. Interestingly, China in spite of a higher population as compared to India, has reported only about 1,000 cases a year since 2005. So is the case with most African countries.

Leprosy is the world’s oldest recorded disease. It affects the nervous system, especially the nerves of the hands, feet and face, and is the leading infectious cause of permanent disability. It is curable, but left untreated it can cause nerve damage, loss of feeling, paralysis and blindness. It is a disease caused by the bacteria Mycobacterium leprae, and is not hereditary. It has an incubation period running up to 10 years before symptoms appear. The mode of transmission is still not conclusively proven, although person-to-person spread via nasal droplets is believed to be the main route. A majority of people contract

it through close long-term contact with an untreated patient. It is not transmitted by mere touch. Health care workers work for years with leprosy patients without contracting it.

Leprosy is not very contagious, and approximately 95 per cent of the people have natural immunity. The earliest sign is a patch on the skin with loss of sensation. Left untreated, it can progress to cause disabilities. Irrespective of age, gender and social class, anyone could be hit. Early diagnosis and adequate treatment are essential to cure the disease and prevent disabilities. Multi-Drug Therapy (MDT), which combines three drugs to kill the bacteria if used in the early stages of the disease, can help avoid disability and disfigurement. Globally there has been much progress since 1982 with the introduction of MDT, a miracle treatment; over 15 million people have been cured.

In spite of declaring elimination — an epidemiological term defining the number of leprosy cases as fewer than one per 10,000 population — much has remained the same with regard to the number of new cases. Individuals with leprosy are still diagnosed late or not treated in the early stages and land up with a deformity. Disabilities lead to their being shunned, isolated and stigmatised; the fear is worse than the disease itself. The global situation continues to be influenced by the Indian scene. Efforts taken by various stakeholders — the Government of India, State governments, the International Federation of Anti-Leprosy Associations, non-governmental organisations, Novartis, the World Health Organisation and others in India is contributing a lot to address the challenge. The government’s efforts to conduct special campaigns and implement action plans in districts with high burden in 2013 and 2014 help. But innovations such as systematic contact surveys, molecular diagnostics, and chemoprophylaxis should be stepped up. Heightened awareness of symptoms suggesting leprosy, and of the fact that leprosy still exists in India, should help control activities.

While India celebrates its near-victory over polio, leprosy continues to haunt it. Concerted efforts are required to ensure timely diagnosis so that disabilities can be prevented, patients are cured and the cycle of stigma and discrimination is broken.

(Dr. G. Srinivas is National Medical Adviser to the German Leprosy & TB Relief Association, GLRA India, and is based in Chennai. E-mail: srinivas@glraindia.org)

February 9, 2014, Opinion: Open page

Engaging the private sector in TB control

A potential game-changer for the programme in India

Tuberculosis is easily one of India’s most critical public health issues, but TB prevention and control efforts face several challenges. Of these, perhaps the most significant is the effective engagement and participation of India’s vast private sector, which manages 60 per cent of all TB

patients.

The private sector is highly fragmented and consists of providers of variable quality. Many TB programme managers may perceive the private sector as their main challenge and feel that engaging them would be outside the scope of their mandate. This detachment between the public and private sector is unproductive and fuels further spread of TB. Patients regularly float from one sector to the other, expending their resources and becoming more and more ill. There is also increasing evidence of a rise in the rates of drug-resistant TB — an indication that all is not well with the management of TB patients in the community.

Why does not the public programme effectively regulate or engage this sector? In many cases, managers are too preoccupied with the implementation of the DOTS programme. Other constraints to this engagement include a lack of trust on both sides, necessary skills and shortage of human resources. Mutual distrust between public and private sectors is not new. It is fuelled by perverse market forces on the side of the private sector and antipathy on the part of the public sector. Private providers have poor compliance with the Revised National TB Control Programme’s (RNTCP) patient management strategies, with errors in diagnostics, drugs dosage and duration. Additionally, treatment adherence is a major issue — patients often stop their treatment or take medication in an irregular manner due to high costs or lack of monitoring. There is disturbing documentation on the use of inappropriate tests and prescriptions by both

qualified and unqualified medical providers, leading to rising patient costs and incorrect diagnosis.

Moreover, private providers perceive TB as a clinical issue and do not always look at the community and public health perspectives of patient care, such as early diagnosis, infection control and prevention of transmission, social and psychological support and a patient-centric approach, which are necessary to achieve cure and halt transmission within the community.

India’s anti-TB programme has in the past floated public private partnership (PPP) schemes, but these have not had the necessary impact, perhaps because of insufficient benefits and incentives for the private sector.

Yet, given that the private sector treats a significant number of TB patients, its engagement is essential to achieve universal access to quality diagnosis and treatment. The sheer strength of numbers underscores the importance of an efficacious PPP model. The truth is that India’s TB burden cannot be substantially reduced unless we engage and successfully partner with the private sector.

The RNTCP is a robust public health programme, having reached over 15 million patients in the past 10 years. It has helped reduce TB prevalence and mortality, in line with the Millennium Development Goals. Similarly, there are numerous examples of clinicians in the private sector who successfully treat and cure TB patients. Yet, negative perceptions from both sides remain a major obstacle to successful partnerships.

A strategic approach to explore PPPs would include mapping the private sector in terms of core competence. Non-profit organisations such as Partnership for TB Care and Control in India (The Partnership) can provide support to State and district TB officers in the mapping exercise. Knowledge Attitude Practices (KAP) studies should explore and identify behavioural barriers within the public and private sector on PPP. The PPP strategy should include a system for accreditation of private facilities that offer the best standards of care. There will have to be stricter regulation of the sale of anti-TB drugs.

The existing PPP framework on offer from the RNTCP needs revisiting and a critical review. The concept of private providers participating through preset schemes from the RNTCP has found very few takers. There are several innovations and models of private-private and private-NGO linkages which should be fostered and scaled up. However, before a PPP model is developed, it

is important to have consultations with key stakeholders including healthcare professionals, non-governmental organisations, the pharmaceutical industry for an ideal and flexible PPP system. The urgency then is for stakeholders to come together to create a strong PPP model for enhanced TB control.

Private providers should be encouraged to disseminate best practices, Standards of TB Care in India (recently brought out by the government), and encourage strict compliance with the Government of India’s ban on serology and mandatory notification of cases. The crisis of partnership in private sector engagement and monitoring of TB control can be addressed only through a participatory dialogue between private and public providers as equal and true partners. Standards of care offered to the patient should be the paramount consideration in the dialogue and the concept of “patients first” and “zero TB deaths” the common goal.

(Dr. Soumya Swaminathan is Director of the National Institute for Research in Tuberculosis, ICMR, Chennai. E-mail: soumyas@nirt.res.in)