Critical Thinking

Drug medicines or other needs such as food

Drug Resistant TB is one of the major challenges being faced in India. The decentralized approach for providing treatment services for DR-TB under PMDT (Programmatic Management of Drug Resistant TB) in India have shown very good and promising results in increasing number of cases put on DR-TB regimen under programmatic conditions. Antimicrobial resistance among patients with various infectious diseases in general and in Tuberculosis patients specifically has become a major challenge to the public health services in India and in Telangana State. With nearly 60-70% of health care access being accessed from private sector in states like Telangana, it is more important to become aware of the challenges posed to the society and in turn to the health care of future generations to come by irrational, incomplete, insufficient usage of antimicrobial agents.

Impediments towards universal access to DR-TB treatment are many, ranging from insufficient donor funding to poor laboratory diagnostic capacity and health system challenges, including the need to encourage ambulatory care models 3. In our settings it was observed that smooth fund flow could be achieved by decentralization coupled with administrative commitment, though there are no quantitative measurements for this change. However, it was clearly felt by the hospital staff that it was easy to mobilize funds for few DR-TB patients in each of the DR-TBCentres compared to mobilizing funds for all the patients in 1 or 2 initial Nodal DR-TBCentres as the case load was high and the funds consumed by the Nodal DR-TBCentres were high in view of the hospital administrators. After decentralizing the proportion spent in each DR-TBCentre was less compared to the overall spending of the hospital and thus could easily get approval for various investigations, medicines or other needs such as food for patients and attendants etc. without a feeling of burden on the administrators.

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Several large scale DR-TB programmes have demonstrated that decentralization will improve access to care and management without compromising treatment outcomes4-7,including programmes that have task shifted initiation of DR-tuberculosis treatment to trained nurses and paramedical staff8. Decentralisation has been a crucial strategy for expanding access to treatment for HIV and has been associated with better patient outcomes than with hospital-managed care, mainly due to improved retention9,10; there is a broad consensus that to improve early health-seeking behaviour, promote adherence to medication, and minimise defaulting, HIV care is best provided as close as possible to the patient’s home and community. These lessons for patient support are clearly applicable to DR-tuberculosis because default rates from care commonly exceed 20%11.In most high-burden settings, the DR-TB epidemic is driven primarily by direct transmission of DR-TB strains. Therefore, efforts to reduce transmission should be directed at diagnosing and treating as many cases as possible and as early as possible12.

Our analysis also demonstrates that decentralized DR-TB treatment Centres at district level could be an intervention that has benefits for the patients in terms of prompt treatment initiation for almost 90-95% of lab confirmed DR-TB patients in lesser time, travel distance and cost for treatment initiation. This also can benefit the health system due to its low cost, further integration and enhanced ownership by harnessing district hospital services.

Conclusions: We conclude by recommending decentralization of DR-TB treatment centres at least upto district levelin every district of India as a cost effective intervention to enable prompt initiation of appropriate treatment of lab confirmed DR-TB patients, keep pace with the growing demand for treatment expected with the expansion of rapid molecular test and the move towards universal DST over the next few yearsthus in turn reducing the chain of transmission effectively.

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