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How AP can saves lives every year & improve healthcare

The health status of Andhra Pradesh has gradually been improving from 2014-end to 2019. In a ranking exercise on health indicators by NITI Aayog, it moved up one ranking among the 21 larger states for its performance in 2015-2016, to eight place from ninth. Apart from the current pandemic, it has been in a progressive place following the measures taken by former Chief Minister N. Chandrababu Naidu between 2014 to 2019.
 
How TB rate worsened in AP
 
According to the Copenhagen Consensus Report, when it came to tuberculosis (TB), one of the key measures on which states are judged, AP didn’t do so well. The state saw the most significant decrease in the success rate of treating new confirmed cases, from 90.4% in 2014 to 88.5% in 2015, as compared to the other larger states.
 
For Andhra Pradesh and for every state, managing TB is especially important because in addition to claiming many lives, it has a cascading effect, since one case treated saves others from being infected. Managing this killer disease and especially the costly and increasing multi-drug resistant variant will mean the health system will have more money to tackle other health priorities.
 
AP had managed to identify more cases: the total case notification rate of TB per 100,000 people increased from 136 in 2015 to 145 in 2016. The national strategic plan for TB elimination, launched in 2017, set out a renewed ambition to control and eradicate the disease. The crucial question is how to make this happen?
 
Nimalan Arinaminpathy, a senior lecturer in Mathematical Epidemiology at the School of Public Health, Imperial College London, has explored two options that would improve the response to TB, and thus lift AP’s health performance.
 
Solutions that can boost AP’s health indicators
 
Dr Arinaminpathy’s first proposal is to increase the quality of TB care in the private sector, by creating a Public Private Support Agency (PPSA), also mentioned as one of the critical comp-nents in the NSP 2017-25 (National Strategic Plan). Mumbai and Patna have already engaged such agencies to identify and enlist private providers for case notification and follow up, supported by public funds and overseen by the national TB programme.
 
The Government of Andhra Pradesh had also engaged with private sector health providers for TB care and control. About 13% of TB patients notified are from private sector.  Lifting the standard of TB care in the private sector is critical, since the National Strategic Plan (NSP) 2017-25 identifies that well over half of TB infected first go to private clinics.
 
Poor patient management can delay diagnosis
 
Poor compliance with patient management strategies and use of inaccurate tests can delay diagnosis, thus permitting ongoing transmission, while a general lack of treatment support means that many private patients do not complete the 6-month standard TB regimen. This leads to poorer outcomes than in the public sector, and in-creases the risk of multi-drug-resistance.
 
Importantly, unlike earlier public-private mix approaches, private providers would continue to manage TB patients. This is crucial to engage the private providers, so they don’t just see the purpose of the PPSA to 'divert' the patient to the public sector.
 
To estimate the cost, Dr Arinaminpathy uses pilot study costs. He estimates that it will only manage to reach half of TB patients. In this scenario, the cost would be Rs. 30 lakh per year between now and 2050. This would increase the number of TB patients undergoing high-quality treatment by 2040 from 27.3 thousand to 32.9 thousand. This would save 2,264 lives every year on average, or 7.6% of the deaths that might otherwise have occurred.
 
To enable comparison of this policy with other interventions, Dr Arinaminpathy uses cost-benefit analysis to put into monetary terms the benefits of saving lives and reducing disability and treatment times. He finds that every rupee would generate Rs. 113 of benefits. That’s a remarkable ‘return on investment’.
 
The second intervention adds improved case-finding. Currently, TB services largely wait for symptomatic patients to show up to a clinic. Case-finding aims to go into the community to detect TB cases. This would diagnose patients earlier, shorten the period over which they are infectious, and reach under-served populations.
 
Why Vizag, Vijayawada are critical in implementation process
 
As in the NSP 2017-25, the research sets urban slums as a priority area: they have just 10% of the population but account for one-quarter of the TB burden. This is crucial for cities like Visakhapatnam and Vijayawada which have a high proportion of urban slums – around 40 % according to the 2011 census.
 
In these areas, under the proposal screening would be conducted once per year for TB using X-rays. Possible cases would be diagnosed using accurate, rapid tests. If positive, people would be referred to the public sector for treatment. This intervention would be supported, staffed and implemented by the national TB programme.
 The analysis highlights two compelling approaches that could strongly boost AP’s health performance, ensuring not only that thousands of lives are saved, but that resources are well-allocated so that the system runs better for all.
 
In combination with private sector engagement, the cost for the first years would be around Rs. 48.1 crores. Crucially, less TB will cut multi-drug resistant cases by up to 80%. Since these cases are much more expensive, it will mean much lower costs in later years, opening up opportunities for more spending on other health care challenges.
 
Case-finding would avert an average of 4,450 TB deaths per year, or 15% of deaths that might otherwise have occurred. The analysis shows that each rupee spent generates a return on investment worth Rs. 120.

 

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