The decline of TB in the developed world began long before the discovery of TB drugs. This is an important lesson for India, says Kanchan Mukherjee
Tuberculosis is one of the leading killer diseases in the developing world, with 6.3 million newly diagnosed cases reported in 2016. The emergence of multidrug resistant TB (MDR-TB) has further complicated the problem, both in terms of treatment challenges and costs, which is why when bedaquiline was developed as the first new medicine for TB in more than 40 years, and clinical trials showed it improved cure rates, it was broadly welcomed.
India, which has one of the world’s largest populations of TB patients, currently offers the drug as part of second line treatment for patients with MDR-TB at pilot sites under a conditional access programme (CAP). However, once the CAP is over, if the Indian government decides to continue providing bedaquiline, it will have to purchase the drug at the local market price. It’s critical that before any wider rollout occurs, the government carries out a thorough budget impact analysis, detailing what it will cost to fund bedaquiline on the national TB control programme. With India bearing a large part of the world’s burden of MDR-TB, the way the country tackles this disease will have a substantial impact on the global movement for TB elimination.
The current cost of a drug-sensitive TB treatment course as per the national guidelines is around (US)$50 in India, while the cost of the treatment course of MDR-TB, including bedaquiline and other second line drugs, is estimated to be around $3500. Considering that there are around 150 000 cases of MDR-TB in India—a figure which is projected to rise—the government will need to take a hard and analytical look at the costs of rolling bedaquiline out.
It’s easy to see why rolling out bedaquiline would be politically popular. For a policy maker, the introduction of a new drug offers maximum visibility in a short span of time. However, it doesn’t address the structural problems that are also responsible for the spread of TB in India: for example, overcrowded housing, poor ventilation, poor nutrition, etc. Countries that have managed to eradicate TB were able to make great gains by investing in public health measures that addressed these social determinants. The decline of TB in the developed world began long before the discovery of TB drugs. This is an important lesson for India.
There is a huge opportunity cost attached to investing in bedaquiline in India to treat MDR-TB. Bedaquiline may help patients already suffering from MDR-TB, but at its current price, the cost implications are huge if it is to be made part of the national programme for TB control. If it is to be at all feasible, the price of the drug will have to be brought down substantially.
Furthermore, in the rush to roll out a new intervention, we mustn’t forget that there are cost effective strategies beyond drugs, which could help prevent the development of multidrug resistance. For example, incentivising appropriate prescription practices for standard TB treatment and improving compliance/adherence rates. Investing in robust, multisectoral prevention strategies like these would offer much better and long lasting value for money in the Indian context.
Kanchan Mukherjee is a medical doctor who specialises in public health, health policy, and health economics. He is currently a professor at the Tata Institute of Social Sciences, Mumbai.
Competing interests: I have read and understood BMJ policy on declaration of interests and declare the following interests: None.
Editor’s note: The BMJ changed the first sentence of the third paragraph of this article on 13 September 2018. The original sentence did not state explicitly that the $3500 cost quoted includes second line drugs as well as bedaquiline. The rewording addresses a concern raised in correspondence by Johnson & Johnson, the company that manufactures bedaquiline.