TB treatment: an investment on the future

An election sharpens attention on how to ensure that the poorest in society benefit. As the next general election approaches, it is timely to focus attention on the challenge of Tuberculosis (TB) — a scourge affecting the poorest Indians the most — because its treatment is one of the most cost-effective transformative interventions that can be made.

New research undertaken by India Consensus squarely places TB treatment among the top investments that India can make in order to help achieve the UN’s Global Goals.

There are more than 169 Global Goal targets which national leaders agreed to achieve before 2030. This dizzying array of targets has left most countries allocating money in the dark, without knowing which targets achieve the most.

However, in a world-first, India has commissioned a rapid-fire study to assess 100 government programmes that advance the 169 targets, to establish which achieve the most. This started with the Niti Aayog, which identified the government programmes, and then asked India Consensus, a Tata Trusts and Copenhagen Consensus collaboration, to study them.

The specific target on TB promises “by 2030, end the epidemics of AIDS, tuberculosis, malaria and neglected tropical diseases and combat hepatitis, water-borne diseases and other communicable diseases”. For tuberculosis, the indicator is “tuberculosis incidence per 1,00,000 population” and the objective is to move incidence towards zero.

In policy terms, that is achieved by increasing the funding of the Revised National Tuberculosis Programme (RNTCP). The intention with this analysis is not to assess how effective the RNTCP has been so far. Instead, it answers the more relevant question: ‘how effective will more funding to the RNTCP be in helping reduce TB incidence and hence progress towards the Global Goals target?”

There are two reasons why TB treatment ranks so high. Firstly, the costs of treatment are generally cheap, at about Rs 20,000 per patient treated, and the cure rate is near 90%. In other words, spending relatively little money today can save a life. Secondly and more importantly, because TB is a contagious disease, identifying and treating a patient today can reduce the number of onward infections. This means more lives saved, less health expenditure in the future, or both.

This second effect is particularly important if it reduces drug-resistant TB, which is very costly to treat and much less curable. Globally, although major forms of drug resistance account for less than 6% of TB burden, their treatment consumes almost 30% of global funding — a pattern also seen in India. There are now numerous studies in India and abroad showing that every rupee spent treating TB creates benefits to society worth at least Rs 100 or more — phenomenal results in terms of public policy.

The Rajasthan case

A recent India Consensus study from Rajasthan, which examined the costs and benefits of engaging private healthcare providers to better identify and treat TB, along with actively searching for undiagnosed TB cases in urban slums, demonstrated the effective nature of control strategies.

In the first year, the costs in Rajasthan would be Rs 11 crore to identify 1,400 more people with TB, of which 1,200 will get treated and 55 lives are saved. The costs rise substantially to Rs 67 crore in the sixth year by which time 2,200 lives are saved. However, after that the annual costs start to fall as the cost-saving impacts of reducing infections start to materialise.

After 10 years of the intervention, there are 15,000 fewer new cases of TB across the state including 1,900 fewer drug resistant infections. Four thousand deaths are avoided. At the same time, costs are Rs 41 crore, less than previous years due to significantly reduced costs of treating drug-resistant TB.

After 30 years, costs are only Rs 36 crore for the intervention, but there are 24,000 fewer infections and 7,700 fewer deaths than would have been without the intervention. On average, about 5,000 deaths are avoided for a cost of Rs 24 crore per year though, of course, these averages mask the dynamic nature of TB control. Every rupee achieves more than Rs 100 of benefits.

These figures are just for Rajasthan, so national results will vary by state. But one thing is very clear: TB treatment is a phenomenal investment. It saves lives now for relatively little cost and it reduces transmission and public treatment costs long into the future.

(The writer is president of the Copenhagen Consensus Center and visiting professor at
Copenhagen Business School)