According to the Centre for Disease, Dynamics, Economics and Policy, India bears the highest global burden for tuberculosis (TB), approximated to be around 30% (Pandey et al. 2017). India has been successful at eradicating smallpox and polio, but has not made the same kind of progress with TB. Today, about 10% to 50% of all TB patients in India fail to complete treatment, depending on the type of TB the patient has (Bagchi et al. 2010). TB treatment involves taking multiple medications daily for months to years, depending on the level of drug resistance, and failure to complete treatment as prescribed increases the risk of patient morbidity and mortality, disease relapse, drug-resistance, and transmission of TB. Individuals who have been diagnosed with TB have the intention of getting better but often end up being non adherent with the medications. Lack of a comprehensive and holistic understanding of barriers to and facilitators of treatment adherence is currently a major obstacle to finding effective solutions to non adherence. This article achieves three objectives: (1) reviews various determinants of low medication adherence among TB patients in India; (2) evaluates various interventions that have been tried and explores the reasons why some of them are more effective than others based on delivery challenges; (3) recommends some new interventions that have shown results in other countries that could be implemented in India going forward to improve medication adherence.
Tuberculosis is the leading infectious cause of death globally, even though most forms of TB are curable. The World Health Organization (WHO) has estimated that about 8 million people worldwide are infected with Mycobacterium tuberculosis and each year 1.87 million die of it. Of these 8 million, in India, the estimated incidence figure for TB is almost 2.2 million. This indicates that not only is the burden of disease in India for TB very high. However, when we look into the issue more carefully, we can see that the diagnosis is not the main bottleneck because even currently the diagnosis rate is an estimated incidence of 85 positive smear cases per a population of 100,000. This means that of the 2.2 million patients, 45% chose to get tested early and were diagnosed correctly through the healthcare system (Bagchi et al. 2010).
In the 1960s, India initiated the National Tuberculosis Programme (NTP) to combat TB. Expert reviews undertaken by Indian government indicated that less than 30% of patients enrolled completed the treatment. In 1993, the NTP incorporated WHO recommended Directly Observed Treatment Short Course (DOTS) global strategy, and was known as the Revised National Tuberculosis Control Programme (RNTCP)(Cross et al. 2019). This was because they wanted to improve medication adherence for the TB treatment and thought that by enforcing a way in which another person monitors the patient will be effective. India is currently the second largest DOTS provider in the world after China. The unusual aspect of the DOTS treatment is that it takes custody of the drugs away from the patient. In order to take medication, a patient usually needs to report to a health center, where drugs are dispensed and a health worker directly observes the ingestion of the polls.
It is important to realise that when it comes to eradicating TB in India, it is not due to the usual factors of cost, lack of research and technology for treatment. The medications for TB currently as a part of the DOTS program have negligible costs and are almost free for a lot of patients in public hospitals. The diagnostic test is not expensive either and very freely available with great coverage across most parts of India. One of the greatest bottlenecks when it comes to treating and eradicating TB is the “intention-action” gap where individuals who have been diagnosed and who have the medications, often discontinue the treatment midway or fail to stay consistent with their medication.