In 2007, during his doctoral studies at Massachusetts Institute of Technology’s (MIT), Manish Bhardwaj and his colleagues won the “MIT Yunus Challenge” for their innovation on improving adherence of patients to tuberculosis (TB) treatment. After completing his Ph.D. Bhardwaj decided to work full-time in the public health sector and, along with his colleagues, launched Innovators in Health, a non-profit organization to “develop technology to improve TB treatment delivery in rural areas.” The first initiative envisioned was a TB care programme called “Aahan,” (meaning “the first ray of sunlight” in Hindi), in partnership with Prajnopaya Foundation and the Swasti Seva Samiti.
Bhardwaj identified DalSinghSarai, a town in the northern Indian state of Bihar about 90 kilometres from the state capital Patna, as the site for the pilot programme in 2010. He chose this town because the TB mortality rate here was close to the average among districts in Bihar and secondly, Bhardwaj had developed good relationships with local leaders in DalSinghSarai because of his successful development work in the area.
Tuberculosis is an infectious disease primarily caused by a bacterium called Mycobacterium tuberculosis (MTB). Globally, more than two billion people (about one-third of the world’s population) were infected with MTB in 2009, with an estimated 9.4 million new cases of TB reported each year.
Although it was largely a curable disease, Bhardwaj discovered to his surprise that TB killed around 300,000 people a year in India. In 2010, the TB mortality rate in India was 23 cases per 100,000, with a prevalence of 249 cases per 100,000 In 2011, an estimated 40% of the Indian population had latent TB infection[2],which comprised 21% of the global TB burden. It was estimated that the annual direct and indirect cost of TB in India was around US$24 billion. To combat the problem the Indian government launched Revised National TB Control Programme (RNTCP), in 1992, which incorporated Directly Observed Treatment-Short Course (DOTS)[3], WHO’s global TB control strategy.
TB is transmitted through air when a person with active infection coughs or sneezes. About 85-90% of TB cases are pulmonary[4] i.e., affecting the lungs. Left untreated, each person with active TB can infect between 10 and 15 people every year on average. TB symptoms are vague in the initial stages and are so prevalent in endemic societies that they make early detection of TB quite difficult. Low income individuals are also at higher risk because TB spreads in crowded places such as households, schools, workplaces and marketplaces and also because they are more likely to have weaker immune systems due to inadequate nutrition[5].Approximately 75% of TB patients were between the ages of 15 and 54 years of age.
A variety of methods are available to diagnose TB in a suspect population, including clinical examination, microbiological examination and other blood tests.
Treating TB is a long-term process. A TB patient must take antibiotics for about six to nine months. There are no vaccines that are reliably and universally effective against all TB infections in all geographies. As a result, the main focus of preventive measures is on behavioural interventions, such as educating communities about coughing etiquette.
There were several challenges for treating TB in India. According to WHO the current choice of TB diagnostic tests in the private sector often led to misdiagnosis, mistreatment and potential harm to public health. Physician behaviour was often driven by dubious commercial incentives rather than the accuracy of the tests. A rural resident survey, conducted by Bhardwaj, revealed that about 60% of the population had not visited a government hospital in 15 years. The findings also suggested that about 35% of all TB treatment in the private sector fell outside national and international treatment recommendations and constituted non-recommended strengths[6].
DalSinghSarai, like much of the country, faced a critical shortage of qualified doctors[7]. Due to this scarcity, most of the rural population relied on untrained and informal healthcare providers called rural medical providers (RMPs) as the first point of medical care instead of going to a trained doctor. RMPs had little or no formal medical qualifications, with many lacking even a high school diploma. Consequently, they often offered inexpensive but improper remedies.
Before designing the programme, Bhardwaj spent three months conducting surveys in target communities to understand the roles of the key stakeholders in the healthcare delivery chain. He undertook extensive fieldwork to understand the healthcare infrastructure in rural India[8] and delivering of TB care in the private and public healthcare sector and the several challenges that plagued them. He made some important discoveries related to diagnosis and treatment of the disease after close scrutiny of TB Impact measurement[9] and TB prevalence and mortality[10]in India. By and large, people were sceptical about the quality of treatment provided in the public healthcare system. Almost 90% of patients chose private healthcare over the public healthcare system. In the public healthcare system the lab and pharmacy facilities were below par and understaffed while
Bhardwaj’s challenge was to design an appropriate operating model for Aahan. Should Aahan collaborate with private hospitals, rural medical practitioners or public hospitals or all of these? After mulling over the options he narrowed down to some promising interventions: more accurate diagnostic technologies, such as fluorescence microscopy and GeneXpert; referral of patients to the government TB programme by RMPs; and actively identifying TB cases with the assistance of community health workers. Bhardwaj knew that he would have to link the impact of all the above interventions to the major outcome indicators for TB control, such as new infections per year and the case detection rate.
He knew that he would need external funding to actually initiate and run the program. The likelihood of obtaining funding, and its potential size, depended on the effectiveness of the chosen interventions that formed the core of the program. If he were able to quantify the impact of these interventions, it would be easier to convince donors to fund the program.
About the Authors
Professor Sarang Deo, Professor Milind Sohoni, Jagdeep Gambhir and Priyank Arora prepared this case solely as a basis for class discussion. This case is not intended to serve as an endorsement, a source of primary data, or an illustration of effective or ineffective management. This case was developed under the aegis of the Centre for Learning and Management Practice at the Indian School of Business.
End Notes
[1] RNTCP India Annual Report, 2011.
[2] Ibid.
[3] Source: http://www.who.int/bulletin/volumes/89/8/11-087510/en/index.html, last accessed on October 18, 2012
[4] http://tbcindia.nic.in/pdfs/Tuberculosis%20Control%20in%20India11.pdf, last accessed on August 20, 2012.
[5] http://www.healthinitiative.org/html/toolkit/indperspectiveprint.htm, last accessed on January 23, 2013.
[6] Wells W. A., Ge, C. F., Patel, N., Oh, T., Gardiner, E., and Kimerling, M. “Size and Usage Patterns of Private TB Drug Markets in the High Burden Countries,” PloS One, 2011.http://www.plosone.org/article/info%3Adoi%2F10.1371%2Fjournal.pone.0018964, last accessed on January 23, 2013.
[7] India has 60 doctors for every 100,000 people compared with 257 in the United States. “India’s Fake Doctors: Quackdown,” The Economist, February 21, 2008. http://www.economist.com/node/10727817
[8] Rural health statistics, Ministry of Health and Family Welfare, Government of India, New Delhi, 2007.
[9] Source:http://whqlibdoc.who.int/publications/2009/9789241598828_eng.pdf, last accessed on October 20, 2012.
[10] Source: http://hetv.org/india/nfhs/nfhs3/NFHS-3-Chapter-13-Morbidity-and-Health-Care.pdf(page-5), last accessed on October 18, 2012