As the world continues its relentless fight against tuberculosis (TB), a beacon of hope shines from India, Indonesia, and China. These three countries, together bearing almost half of the global TB burden, are confronting the challenge head-on and pioneering innovative approaches to integrate TB care into Universal Health Coverage (UHC), setting a precedent for global health advancements.
The ambitious targets set in the Sustainable Development Goals 3.3 (SDG 3.3) and the End TB Strategy have galvanized international efforts, aiming for a 90% reduction in the number of TB deaths and an 80% reduction in the TB incidence rate compared with levels in 2015. Since 2015, there has been growing and bolder leadership by policymakers in India, Indonesia, and China toward ending TB epidemic and advancing Universal Health Coverage. At the heart of this global endeavor, Universal Health Coverage reforms in the three countries embody a deep commitment to ensuring access to TB care and financial protection for TB patients.
New Strategies to End TB
By integrating TB diagnosis and treatment into UHC, India, Indonesia, and China are building more equitable and accessible healthcare systems. India and Indonesia, with their large number of private providers and diverse healthcare delivery landscapes, have adopted public-private mix (PPM) models to expand the reach of TB services, leveraging the strengths of both private and public sectors to enhance care delivery. Meanwhile, China’s more centralized approach to TB care through hundreds of TB-designated hospitals and the broader public health system ensures coordinated screening, referral, diagnosis, and treatment follow up, exemplifying how structured public health initiatives can achieve significant impacts.
The comprehensive financial strategies underpinning these health reforms are equally pioneering, moving from the historical vertical financing for TB towards better alignment with universal health coverage. India’s TB screening, diagnosis and treatment programs are financed under the National TB Elimination Program (NTEP), while TB-related hospitalizations are covered under the tax-funded Pradhan Mantri Jan Arogya Yojana (PM-JAY) health insurance scheme. Notably, both NTEP and PM-JAY are also designed to cover private-sector TB care, which is widely utilized by TB patients in India. In Indonesia, free essential TB drugs and supplies were provided to public primary healthcare centers (PHCs) and NTP-linked private providers through National TB Program (NTP). The National Health Insurance program, Jaminan Kesehatan Nasional (JKN), covers the TB-related costs if a patient accesses TB-related services in secondary and tertiary level health facilities, mainly inpatient services. In China, NTP offers patients essential TB diagnostic tests and first-line anti-TB drugs free of charge. The social health insurance schemes cover almost all TB-related hospitalizations，specialist outpatient visits and some second-line drugs. TB screening and follow-up is also included as part of its National Basic Public Health Service Package implemented at primary care level.
Innovations for better TB outcomes
In all three countries, there are efforts to innovate TB diagnosis and TB care delivery. India has been scaling up game-changing innovations, such as Bedaquiline (BDQ) short-course treatment for multi-drug resistant TB (MDR-TB), significantly shortening the treatment duration for MDR-TB at a national level by 2022. Social health insurance schemes in China also started to cover BDQ since 2019, though with some co-payments that vary across provinces. Regarding NTP governance and management, India and Indonesia have scaled up private provider engagement schemes, including using output-based contracting for private providers, as well as IT tools to ensure seamless information exchange between public and private sectors. India has also leveraged the national Direct Benefit Transfer (DBT) platform to directly transfer cash into over 1.5 million TB patients’ and provider’s bank accounts to provide financial support, and also as economic incentives for seeking TB care and adhering to treatment. Several programs in India also piloted mobile digital X-ray and AI-based diagnostics support for TB.
Besides, utilizing market-based strategies to make essential diagnostic tests more affordable has marked a significant leap forward in TB control efforts. The Initiative for Promoting Affordable and Quality Tuberculosis Tests (IPAQT) in India was launched in 2013 as a market-based approach to negotiating lower prices for higher volumes of testing. It resulted in a 30%- 50% decrease in price and a 10-fold increase in X-pert tests. It has demonstrated how collaboration between private labs and international funders can lead to more accessible TB diagnostics.
Gaps remain in health systems and policies offering new opportunities
While all three countries continue this strong momentum of a more integrated approach to TB care as part of UHC investments, market failures in TB control have not yet been adequately addressed, and some policies on NTP programs and national health insurance schemes can be better aligned. For instance, national health insurance schemes in the three countries cover primarily inpatient services, while most patients receive outpatient services during the treatment period. Therefore, patients who have to use second-line drugs, either due to drug resistance or adverse reactions towards free first-line drugs, have to pay most costs out-of-pocket, thus facing financial burden. This funding gap needs to be filled either through specialized programs in NTP or reforms in their health insurance policies. In addition, both NTPs and social health insurance programs should continue to focus on improving the quality of TB care in both public and private sectors through a mix of “Carrot and Stick” approaches.
As we look to the future, these countries’ experiences offer valuable lessons and inspiration for the global community. Integrating TB care into broader health reforms, embracing innovative financing and delivery models, and the commitment to partnership and collaboration illuminate the path forward. With continued dedication and shared learning, the goal of ending the TB epidemic by 2030 is not just a vision but an achievable reality.
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https://doi.org/10.1016/j.lanwpc.2024.101045
