Tuberculosis control needs a complete and patient-centric solution.

Whether it is mobile phone service or vacation travel, good businesses know that success depends on providing a complete and customer-centric solution. Should patients with tuberculosis not be offered a complete solution that is patient-centred? After all, millions are affected and a large market at the base-ofthe-pyramid remains unserved. A complete and patient-centric solution will not only include care that meets the International Standards for Tuberculosis Care, but also be delivered with dignity and compassion, grounded in the reality of patients’ lives as they navigate the long pathway from symptoms to cure. Such solution-based innovation requires a systems-thinking approach that must place patients at the centre of design strategies, recognise their clinical and psychosocial needs, and be cost-effective. Are tuberculosis patients in high-burden countries currently getting such a patient-centric solution? Let us consider India, which accounts for quarter of all tuberculosis cases in the world. Whether patients in India seek care in the public or the private sector, they struggle to get a complete solution. Although the Revised National Tuberculosis Control Programme (RNTCP) has done well to reach scale and provide free diagnosis and treatment for patients with drugsensitive disease in the public sector, the programme falls short in making sure that all patients get screened for drug resistance and in ensuring adequate therapy for all patients with multidrug-resistant (MDR-TB) and extensively drug-resistant tuberculosis. Of the estimated 64 000 cases of MDR-TB in 2012, only 17 373 cases were diagnosed under the RNTCP. The diagnostic infrastructure in the public sector relies mainly on sputum smear microscopy that cannot detect drug resistance. It is only when patients fail to get better on standard treatment, or have recurrence of tuberculosis, that they get screened for MDR-TB, resulting in morbidity, continued transmission, and movement of patients from the public to the private sector. Recognising these problems, the RNTCP is actively scaling up capacity to diagnose and treat MDRTB. If adequately funded and successful, these initiatives should improve patient experience in the public sector. But the stark reality of tuberculosis in India is that 50% of all cases are managed in the private sector, where the quality of tuberculosis care is suboptimal with inaccurate diagnosis, non-standard drug prescriptions, and limited effort to ensure treatment adherence. Also, private practitioners often do not screen for drug resistance and empirical antibiotic abuse is rampant. All this means that drug resistance can emerge or worsen, with poor outcomes. Lastly, out-of-pocket expenditure in the private sector can be catastrophic. Are there examples of initiatives that address the above systemic problems? Operation ASHA is a nongovernmental organisation that extends the RNTCP model, and uses public sector diagnostics and drugs to orchestrate a solution by establishing community-based treatment centres and ensuring adherence using local community providers and partners. It also leverages biometrics to increase efficiency and effectiveness. It relies on donors and the public sector for funding. This social enterprise model, however, does not offer a solution to patients who seek care in the private sector. World Health Partners is a donor-supported social marketing and social franchising model that delivers affordable reproductive and primary care (including tuberculosis) in underserved rural areas, by leveraging local entrepreneurs and informal providers and by connecting them to the formal For Operation ASHA see http://www.opasha.org/