CNS: "Be faithful in small things because it is in them that your strength lies"

Shobha Shukla - CNS (Citizen News Service)

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"Be faithful in small things because it is in them that your strength lies" are the immortal words of Saint Mother Teresa, which sum up what Dr Kuldeep Singh Sachdeva asserts to hasten the pace of progress for a disease-free India. Dr KS Sachdeva has healed thousands of patients in a tertiary level hospital in India’s capital Delhi, has served an illustrious inning at India's national tuberculosis programme and is now serving as Deputy Director General at the national AIDS programme in India.

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He spoke with CNS (Citizen News Service) at the sidelines of the 9th National Conference of AIDS Society of India (ASICON 2016). This interview is part of CNS Inspire series – featuring people who have decades of experience in health and development, and learning from them what went well and not-so-well and how can these learnings shape the responses for sustainable development over the next decade.

One who can move mountains starts with the little stones

Wisdom of Confucius has only gained relevance as ages whizzed by. Dr KS Sachdeva served as a senior clinician in a tertiary level hospital in Delhi for almost two decades. But a small quirk of fate, got him involved with Pulse Polio programme of Delhi state government and thus ushered his long inning in public health. It was not so easy for a doctor who thrived on curing patients, but persistence paid off well when major benefits to public health started appearing after years of efforts.

“I realized that the public health work is equally challenging and difficult to implement on the ground – as difficult as making a difficult diagnosis in a clinic – and also as interesting and enthralling as clinical medicine can be! One might be treating a thousand patients in clinical practice but one good decision at administrative or public health level can benefit and save the lives of hundreds of thousands of people. As years passed I gained confidence in public health policy making, making a difference and delivering things on the ground” said Dr KS Sachdeva.

Simple managerial processes helped save millions

“One of the things that satisfy me when I look back is when we developed the essential drug list and essential list of surgical consumables for the government of Delhi, and then carried out procurement. Through a little simplification of the managerial process of procurement of drugs and surgical consumables, the cost to the health system came down by 40%” said Dr Sachdeva sharing this pivotal incident which took place almost 15 years back. This saving means that the government can serve more people with the same resource allocation. The cost of procurement was almost INR 500 crores at that time. So a 40% saving translated into savings of over INR 200 crores (INR 2 billion). “Back then the shortage of drugs we used to see in Delhi government dispensaries and hospitals actually become non-existent because of the essential drug programme” he added.

Strengthening India's laboratory capacity to detect drug resistance

Soon after entering the public health arena from clinical domain, Dr Sachdeva moved to the Ministry of Health and Family Welfare of Government of India and joined the Revised National TB Control Programme (RNTCP). “When I had joined RNTCP, the programme catered only to patients of drug-sensitive TB and patients of drug-resistant TB were not attended at all. So we began rolling out the programme for drug-resistant TB way back in 2007,” shared Dr Sachdeva.

Accurately diagnosing drug-resistant TB and treating people with effective drugs are some of the essential components of programmatic management of drug-resistant TB. But in 2007, very few laboratories existed in India that could ably test drug resistance. These laboratories are technically complex and financially resource intensive to establish. These laboratories are bio-safety level III (BSL-III) laboratories where solid, liquid cultures and polymerase chain reaction (PCR) Line Probe Assays and other tests are done for drug resistant TB.

“One major challenge was that in 2007 there were hardly any laboratories that could detect drug resistant TB. So our major thrust was in developing infrastructure for programmatic management of drug-resistant TB (PMDT). Between 2007 and 2016, close to 650 molecular diagnostics facilities (almost one in each district); 50 Line Probe Assays (LPAs) laboratories, about 40 odd liquid culture laboratories, and 50 odd solid culture laboratories have been established in the country. The number of patients of drug-resistant TB who have cumulatively been put on treatment is over 125,000. Had we not started this programme back then, and not expanded it in an exponential way, we would not have been able to address the challenge and difficulties of these [drug resistant TB] patients today. Through our treatment for drug-resistant TB alone we have saved 60,000 - 70,000 lives, improved quality of life and reduced suffering of the patients' family,” shared Dr Sachdeva.

Testing TB patients for HIV was vital for public health

TB continues to be a lead killer of people living with HIV (PLHIV). If latent TB (not active TB disease) or active TB disease is diagnosed early in PLHIV, then TB can be treated. TB is curable. Testing TB patients for HIV makes enormous public health sense and is one of the key components of TB-HIV collaborative activities.

“Initially only those TB patients who reported a high risk behaviour were offered HIV testing in the national TB programme. But in 2007-2008 we stressed on making the coordination between TB and HIV a more holistic one and that is how we began offering HIV testing to every TB patient. Operational research studies done in 2014-2015 show that if we offer HIV screening to even those people who are presumed to have TB or are symptomatic for TB, it results in a good yield of new HIV cases, thus leading to very early diagnosis at times. So we introduced the policy of provider-initiated testing and counselling (PITC) of presumptive TB patients and diagnosed TB patients for HIV. PITC yield of new HIV cases is over 2% to HIV programmes, which is the highest percentage contribution compared to other such initiatives in key populations for HIV,” shared Dr Sachdeva. People testing positive for HIV seek care from existing government facilities offering HIV related care and ART.

These small changes that we made in our existing systems, resulting in positive public health outcomes, do satisfy me and uplift my morale too,” reflects Dr Sachdeva.

‘Change is never easy’

There indeed are complex challenges confronting our health programmes. Ushering a positive change in public health is not easy. Whether it is HIV or TB or other specific health programmes in India, one of the challenges which people often refer to is engaging private healthcare sector. Despite innumerable efforts to engage private sector in public health, successes have been sketchy, few and far in between. Solving this riddle continues to haunt us till date and the blame game is on, at times, rightly so.

As the old adage goes: We do not grow when things are easy; we grow when we face challenges. Dr Sachdeva feels this is an area where a lot remains to be done to optimize public health outcomes.

“We did realize that a lot of patients are seeking treatment from outside the programme [RNTCP]. So we began initiatives to involve the private sector to be able to reach these patients. One of these initiatives was standardizing treatment options, which are common for both public and private sector. That is why we developed an enabling 'Standards of TB Care in India' document, which talks of common standards across public and private sector. It also helped us in gaining the confidence of the private sector. We also made TB notifications mandatory – but it is not truly mandatory as it is an executive order and practitioners are encouraged to notify TB patients so that the programme has a better sense of TB load within a community and we can address it optimally. When I look back, I realize that we have not been very effective in involving the private sector on scale. This is one area we need to lay more emphasis on-- involvement of private sector in TB programme, and same holds true for HIV programme” said Dr Sachdeva.

“At this conference [ASICON 2016] I interacted with 5-6 drug manufacturers and tried to get a sense of their annual sales with the intent to have an idea of the number of patients outside of the National AIDS programme. It roughly translates to about 100,000 patients who do not seek HIV care from National AIDS programme. There could be many reasons for this– may be they do not want to visit government facility or be recognized as having HIV. So if we can make processes which enable patients to seek care in confidence and they can repose faith in their providers that they will not share their status with anybody else (which is a national policy but somehow confidence in patients may be lacking), perhaps we can get more patients on board, provide them treatment free of cost and offer them good quality services.”

“So this is one area we aim to work on – not only with patients but also with their providers. Patients may choose to remain with their [preferred] providers but we get to know of how he or she is doing and how we can link our services with those patients” shared Dr Sachdeva.

Next goalpost: Bridging the gap

“We should be developing models of care which are community oriented and public health oriented and get all stakeholders onboard. While specific national programmes are engaging stakeholders, but more or less, they are working within their silos – we should be bridging that gap” emphasized Dr Sachdeva.

An enabling environment for health seeking behaviours is also a part of progressing towards health justice. “Involving more community members to take care of their own health, demystifying some of the treatment options for complex diseases, and building the capacity of health personnel to address these public health issues, might be some of the key priorities for the near future” suggests Dr Sachdeva.

Innovative health financing is indeed becoming a compelling priority. "We should be leveraging resources beyond the Ministries of Health. For example tapping into corporate social responsibility programmes, corporate philanthropists, individual donors, there is thinking going on that we should be having a common platform and tapping into these resources" rightly opines Dr Sachdeva. Optimising every rupee or dollar invested in health is not 'a choice' anymore - it is the only choice to make most of what we have!

"We also need to look into human resource beyond what is available in national health system – qualified individuals who are available within the country should be able to contribute for a disease-free India" said Dr Sachdeva.

Moments that glitter as years rolled by

"One of such moments I can think of is when we introduced the essential drug list and essential list of surgical consumables for government of Delhi and then carried out procurement on them, saving 40% of costs incurred earlier. It is satisfying to see such initiatives are sustainable and rolling. Similarly India’s drug resistant TB programme diagnoses and puts on treatment the highest number of patients compared to any other country in the world, and we have treatment outcomes comparable to the rest of the world. Pharmacovigilance and introduction of new drugs is another such moment but there is still a lot of work to do," said Dr Sachdeva. We cannot agree more with him as a lot more needs to happen for ensuring that the new anti-TB and HIV care drugs reach every person in need.

Persistence is key

For those who are beginning their journey in public health, Dr Sachdeva has some words of advise: "One of the messages I will like to give them is that this is a very exciting, challenging and satisfying area, but it is not that the rewards will come instantaneously. Rewards may come after few years after you have put in hard work, as opposed to clinical work where rewards may come within days, weeks or months of putting in hard work. Rewards you see here are very disproportionate to the efforts you may have put in--one policy level change can affect the entire spectrum of lives of the community. We need dedication, patience, and perseverance to see the results of our efforts."

[Watch this video interview] | [Listen or download this audio podcast]