In a video interview, Dr. William Wells, the study’s lead author and Director of Market Access at the TB Alliance, spoke about the usefulness of such a study in present times. He said that as tuberculosis is a public health concern, its treatment was seen as a public sector responsibility till recently. But now, with the exciting possibilities of new TB drug regimens being rolled out in future, it becomes imperative to understand the true makeup of the entire TB drug market in order to plan for the introduction and maximum impact of the new TB drugs.
The results, though startling, only confirm the lingering doubts which were there in some minds—that is there is as much TB drug volume in the private sector as in the public sector, and that the public and private sectors are both major channels of treatment for TB patients.
TB treatment requires multi drug regimens for at least 6 months or more. This type of consistent and supervised treatment, to maximize cure rates and minimize the development of drug resistance, was thought to be more achievable in the public sector, especially in low-income settings this. This was the driving force behind the much publicized DOTS programme, which in India is being currently run as the RNCTP (Revised National TB Control Programme). By contrast, the private sector treatment landscape in these countries is largely unregulated and fragmented; for example, the study detected that 111 different first-line TB drug dosages and combination are sold in the private sector, which is way more than the 14 deemed necessary by Stop TB Partnership’s Global Drug Facility for rational treatment of children and adults. Also, dosages of 35% of TB drugs sold in the private sector fall outside official recommendations.
According to Dr. Wells, “The private sector is keeping alive the confusion that existed previously in the public sector. With this new baseline understanding of the TB drug market, we can no longer ignore the private sector’s critical role in the access equation for TB treatment and in the task of protecting both current drugs and new regimens from the development of resistance.”
The most interesting data revealed in the study is that nearly equal amounts of TB drugs are dispensed in the public and private sectors. There is enough volume in the private drug market to treat 66% of all estimated cases of tuberculosis, as against 67% in the public sector. In four of the biggest high-burden countries – India, Indonesia, Pakistan, and Philippines –enough TB drugs are sold in their private sectors to treat all existing TB patients.
Although far too many first line treatment drugs are available in the private market, there is relatively little MDR-TB treatment drugs available there—similar to the situation in the public sector where supply is far too less of the need. The private sector is not yet filling up the gap. It is treating significantly only 1-10% of MDR-TB patients with anything approaching a full regimen. However, with new, rapid diagnostics becoming available, there is potential for the private market to expand rapidly, thus highlighting the urgency for action now.
The findings for India are more startling. India’s private TB drug market is the largest of all the 10 countries studied and is four times the size of the next largest market of Indonesia. Thus more than 2 million TB cases can be treated with the volume of drugs in the Indian private market. This means that there are more than enough drugs in the Indian private market to treat all the cases of TB in the country. Much of the private sector drug volume consists of dosing strengths outside the national and international standard TB treatment guidelines. Nearly 60% of India’s private market drugs dosing strengths are improper and do not correspond with national and international standard treatment guidelines. This is nearly twice the average for the countries surveyed.
Dr Wells feels that as the private market has already infiltrated in TB drugs sale, it would be worthwhile for these countries to create links between the public and private sector, so that treatment norms are ensured in the private sector. This would be easier than trying to regulate the private sector, although Brazil is one country which has managed to keep TB drugs out of the private sector. Private market TB drug sales can be utilised to improve overall TB treatments in the countries by expanding ‘public-private mix programmes’.
Dr Mario Raviglione, Director of the Stop TB Department at the World Health Organization, also voices similar thoughts: “Most countries covered in this study have public-private mix (PPM) programmes for TB care, and these programmes have shown good results in optimizing TB management by private care providers. However, there is enormous scope to expand these programmes urgently Private providers following best practices should be supported through accreditation and access to free TB drugs from the public sector, while those not doing so should be regulated. Greater government and international support is needed for these efforts and also for improved regulatory oversight and quality assurance of TB drugs. A dual track approach of collaboration and regulation is the logical way forward. We ought to make private providers responsible partners of the public sector in controlling TB and MDR-TB”.
Shobha Shukla - CNS(The author is the Editor of Citizen News Service (CNS). She is a J2J Fellow of National Press Foundation (NPF) USA. She has worked earlier with State Planning Institute, UP. Email: shobha@citizen-news.org, website: http://www.citizen-news.org/ )
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