The need to further augment the public health system to control tuberculosis.

Abstract

We completely agree with Madhukar Pai and colleagues that a complete and patient-centric solution to tuberculosis control should be delivered with dignity and compassion. India’s Revised National Tuberculosis Control Programme (RNTCP), which was recognised as one of the best-run tuberculosis control programmes in the world, has only been able to provide 27% of patients with multidrugresistant tuberculosis with treatment, which is worrisome. Pai and colleagues vouch for patient-centric solutions for complete treatment. However, they do not emphasise the fact that most of India’s population is served by the public health system, with varied quality of services delivered. The scope for the tuberculosis control programme has been increasing from 2006 when the whole country was immunised, and there was a drive to strengthen the programme in the areas of tuberculosis and HIV co-endemicity, drug-resistant tuberculosis, tuberculosis–diabetes, and tuberculosis noti fi cation, without any major modifi cation to the available human resources. The degree of integration expected from the general health system by the RNTCP was not fully achieved; the onus of treatment of a patient with tuberculosis always remained with the RNTCP, rather than the health system. We urge that the public health system in the country is augmented with new workforce strategies and policies to retain human resources and deliver appropriate care to the community. The proportion of gross domestic product spent on health is a meagre 4·1% in India, whereas developed countries, such as the USA, spend more than 17·1% on health care. The private health sector in India is uncontrolled. Strategies and models implemented in a particular place might not be easily replicable in other places. Engagement with the private sector is only a small part of how best to improve health care; strengthening of the public health sector is vital in India. In conclusion, a complete and patientcentric solution can be provided by augmentation of the RNTCP, in terms of good governance of the health system, new technologies, increased investment in the general health system, and political and administrative will to implement high-quality services for tuberculosis care. For delivery of services under the national health programme in a vast country such as India, no replacement for the public health system exists.