The raging coronavirus pandemic has necessitated concentrated efforts to contain the spread of the virus, leading to ‘covidisation’ of the health system. The diagnostic repurposing and redirection of funding, human resources, and infrastructure has led to neglect of other diseases. This was strongly experienced by the ‘big three’ of the infectious diseases, namely, tuberculosis, malaria, and HIV, which cumulatively accounted for 2.4 million deaths worldwide in 2018. India carries a significant portion of the global burden of these diseases, and in terms of number of cases, ranks first in tuberculosis, third in HIV, and fourth in malaria in the world. United Nations’ Sustainable Development Goal-3 (SDG-3) targets the eradication of the ‘big three’ by 2030. This becomes imperative since it is projected that over the next five years, in high-burden settings, deaths caused by malaria, tuberculosis, and HIV could rise by 36 percent, 20 percent, and 10 percent respectively, compared to a no pandemic scenario (Hogan, Jewell and Sherrard-Smith 2020). The pandemic will potentially lead not only to missing targets but also undoing decades of monumental progress.
In May this year, the Delhi High Court, defending the Delhi government’s directive of putting all doctors and allied medical staff under one category, irrespective of their specialisation for Covid-19 management duties, said that such a step was justified given the ‘war-like’ situation created by the pandemic. Madhukar Pai of McGill International TB Centre, Montreal commented, “All diagnostic companies are directing their attention and production capacity to COID-19 tests, (which) might come at the cost of diagnostics for other conditions” (Venkatesan 2020). Truenat machines available at National Tuberculosis Elimination Program sites were employed to ramp-up coronavirus testing. In May 2021, the National Institute of Tuberculosis and Respiratory Diseases (NITRD) was converted into a COVID Care Centre. Roche’s Cobas 6800/8800 system, Cepheid’s GeneXpert Express, and DRQ’s SAMBA II were repurposed from HIV diagnosis to COVID testing.
Restriction on movement and repurposing of testing equipment and centres led to a decrease in testing last year. TB notifications decreased by 38 percent in March -June in 2020 as compared to the same period in 2019 (India TB Report 2021). The closure of private health facilities and small clinics, which act as the first point of care for half of the patients, during the lockdowns, resulted in a plunge in TB notifications by 44 percent in March-April 2020 (National TB Report 2021). India had made great progress towards the elimination of malaria by the target year of 2030 through increased testing, but the lockdown period i.e. April-June 2020 saw a 40 percent decline in testing as compared to January-March 2020. According to a study by John Hopkins University there was a sharp decline of 88 percent in HIV testing at the Integrated Care Centres (ICC) in March 2020 compared to January- February 2020. The HIV testing dropped by 25 percent of the normal capacity in May 2020 and returned only to 35 percent of the capacity by July (McFall, et al. 2021 ). (Complete data is not available for HIV for the year 2020)
Figure 1: Month-wise Comparison of TB Notifications in 2019 and 2020. Source: India TB Report 2021, Ministry of Health and Family Welfare
Figure 2: Month-wise comparison of the number of Malaria tests in 2020 and average of last 3 years. Source: National Vector Borne Disease Control Programme, National Health Mission, Ministry of Health and Family Welfare
Bacillus Calmette-Guerin (BCG) vaccination, used against tuberculosis, dropped in administration rate by 20 percent in the period April-June in 2020 as compared to the same period in 2019 (RCH Reports-Indicator Wise 2020). DOTS registrations in April-June 2020 fell by 40 percent as compared to the same period in 2019 (Shrinivasan, Rane and Pai 2020). According to the survey conducted by Kantar Health, more than a third of the population who are at risk of contracting HIV had either decreased or stopped taking preventive medicines during October-November 2020. April and May are preparatory months for a peak in cases of malaria in July and August. The coinciding of seasonal peaks of malaria with COVID peaks led to disruption in delivery of insecticidal mosquito nets and preventive measures of fogging, fuming and awareness campaigns in 2020 (Watts 2021) (Nema 2021).
The closure of clinics and restriction on movement led to the skipping of medication which risks the emergence of drug-resistant forms of tuberculosis and HIV. India accounts for one-fourth of the global burden of Multi-Drug Resistant Tuberculosis (Shivekar and Kaliaperumal 2020). Missing two or three doses in a month or adherence of less than 97% can develop resistance to antiretroviral medication used against HIV (Godbole 2020). Coinfection of coronavirus and tuberculosis and/or malaria, which have similar symptoms, may lead to misdiagnosis, and is associated with increased severity and mortality. Persons living with HIV are immuno-compromised and are part of the high-risk group to contact coronavirus.
Indian healthcare expenditure, at 1.3 percent of the GDP, fares poorly against the averages of OECD and BRICS countries, which are 7.6 percent and 3.6 percent respectively. The sector saw an increased outlay in the Union Budget 2021, with a 137 percent increase. However, more than a quarter of it was allocated to COVID vaccination. Budget for National AIDS (acquired immunodeficiency syndrome) and STD (Sexually Transmitted Diseases) Control programme remained unchanged at ₹ 2900 crores. Budgetary allocation of the National Health Mission, providing support against vector-borne diseases and tuberculosis, was increased by 9.5 percent. Even after facing the dearth of human resources throughout the pandemic, the budgetary allocation for human resources for health and medical education was increased by only 2.4 percent. An increased investment in the form of increased budgetary allocation for elimination programmes and human resources is needed to undo the effects of the pandemic on these diseases.
Eliud Wandwalo, Head of Tuberculosis at The Global Fund, comments, “This is not a choice between fighting one infectious disease or the other: we must both fight COVID-19 and continue lifesaving HIV, tuberculosis, and malaria programmes, or more people will die” (Venkatesan 2020). The ‘resource-steal’ is feared to store up long-lasting problems for the future in the form of emergence of drug-resistant forms of diseases and delayed target achievements. But there is hope. The pandemic has seen unparalleled collaboration of global partners in innovation to enhance speed and scale to counter a major threat to health security. It paved the way for integrated testing, as seen in bi-directional TB-COVID screening, increased use of telemedicine, and recognition of the role of last-mile health workers. There is a need for increased testing of the big three, which can be complemented by the increased testing capacity due to its overlapping with the COVID testing platforms and equipment. Preventive measures need to be ramped up to control the incidence rates.
(This article was written by Nidhi John under guidance of Dr. Swapna Jambhekar, CPPR Research Consultant)
Views expressed by the author are personal and need not reflect or represent the views of Centre for Public Policy Research.