One of the most interesting experiences from my first trip to Hyderabad in 2013 was the opportunity to see the Directly Observed Therapy Short-course (DOTS) program that Sivananda Rehabilitation Home (SRH) operates. DOTS is the global WHO-backed approach to stemming TB via therapy, and incorporates a range of systems commitments in addition to the titular direct observation of patients taking therapy. On last Friday, we had the opportunity to revisit the SRH DOTS program.
In India, as in many countries, DOTS is administrated by a range of organizations – the government Ministry of Health has ultimate control, but many districts will have the “on-the-ground” responsibility devolved onto an NGO or public-private institution. SRH covers a district with 5 lakh (500,000) patients, 4 clinics, and around 400-500 patients currently under therapy. Each clinic has a lab for performing on-site HIV testing and sputum smears, as well as a team of community health workers tasked with supporting patients through therapy. Roughly 70% of patients go to the DOTS clinic for their three-times-a-week therapy; the other 30% will go to a private clinic or pharmacy closer to their home, where the doctor or pharmacist will monitor the medication administration, with supervision by the local DOTS clinic.
(as a note, we went to one of these local clinics, and it was quite interesting to see what a private clinic looks like. Worth noting that private clinics get R1000/month from the government for providing therapy (for 3 visits x 4 weeks = 12 total patient contacts; R83/contact). This particularly doctor charges R50/consultation (not including diagnostics or therapeutics) – DOTS patients don’t pay, the government pays for them, and I found it notable that the prices were slightly better than his standalone fees. Curious whether fees are adjusted for urban vs rural settings)
It’s hard to take a program’s full scope in when you’re only there for a brief period, but SVH certainly appears to have a highly functional program, and the results they reported (100% cure rate for the 98% who maintained care) are obviously excellent (and, in fact, quite high for any setting). I remain curious about some other aspects of India’s TB approach – notably a one-regimen-fits-all method of therapy for MDR-TB, likely driven by the cost of performing more thorough drug testing – but end on a hopeful note, the graph from the WHO STOP-TB India country profile page of the national TB rate: