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November 2, 2017

The war on TB

  • There is a glimmer of hope with India registering a slight drop in the number of new tuberculosis cases and TB deaths in 2016 compared with 2015. From an estimated 2.84 million new cases in 2015, the number dropped marginally to 2.79 million in 2016, according to the World Health Organisation’s Global tuberculosis report, 2017. Incidence estimates for India are considered interim, pending a national TB prevalence survey scheduled for 2017-2018. In terms of mortality, the drop was from 0.51 million in 2015 to 0.43 million in 2016. The number of deaths and the incidence rate have been falling both globally and in India. The targets set in the End TB strategy are global reduction of 20% in incidence and 35% in mortality by 2020, taking 2015 as the base year. To reach that target, the global drop in incidence has to be 4-5% a year — currently it is about 2% a year. Also, the percentage of deaths should come down from the current 16% to 10%.
  • With India accounting for the highest TB incidence (23%) and mortality (26%) globally, success in realising the End TB targets hinges largely on the country strengthening its systems.
  • The first step in defeating the disease and achieving the targets is to record every diagnosed patient through case notification (that is, when a person is diagnosed with TB, it is reported to the national surveillance system, and then on to the WHO). There was a 34% increase in case notifications by health-care providers in the private sector between 2013 and 2015. It improved from 61% in 2015 to 69% in 2016. But much work remains to improve case notifications as only 1.9 million TB cases in the public and private sectors were notified in 2016, leaving a 25% gap between incidence and notification, the largest in the world. Though notification was made mandatory in 2012, multiple surveys and surveillance data still show large under-reporting of detected TB cases, especially in the private sector.
  • With a higher number of people with TB being tested for drug resistance, the percentage with resistance to the drug rifampicin alone more than doubled to 0.58 million in 2016 over the previous year. Also, the number of estimated multi-drug-resistant TB cases increased marginally to 84,000. But the number of people with MDR-TB enrolled for treatment improved marginally between 2015 and 2016 (from 26,996 to 32,914). For the first time, baby steps have been taken to offer preventive TB treatment to a small (5%) number of people who are HIV-positive, and 1.9% of children below five years who are household contacts of people recently diagnosed with pulmonary TB. Notably, domestic funding (74%, $387 million) for anti-TB work has been more than that from international sources (26%, $124 million). While better funding might help India inch closer to its stated goal of ending TB by 2025, much more is needed in terms of funding and commitment on all fronts.

Moving up

  • India’s surge in the latest World Bank report on “the ease of doing business” around the world — from the 130th position last year to the 100th — could not have come at a better time for the government. Facing sustained criticism of late over its handling of the economy, it was not entirely surprising that Finance Minister Arun Jaitley held a press conference just to discuss the findings of the Bank’s report. He reiterated the commitment to pursue more reforms, especially in areas where the Index still rates India poorly among 190 countries. Prime Minister Narendra Modi has set for his government the target of entering the top 50 in the Bank’s index, from the 142nd rank India was placed at in 2014 soon after he assumed office.
  • Specific steps to cut red tape seem to be paying off, with the Bank recognising India as one of the top 10 countries that have made improvement over the past year, and the only large country to see a significant shift. The introduction of the new insolvency and bankruptcy resolution process, simplifications in the payment of statutory dues such as provident fund contributions and corporate taxes and easier access to credit are among the key changes that spurred India’s latest ranking. It is also notable that India is now the fourth best placed in the world for minority investors, well ahead of several developed nations.
  • The Bank’s report, based on executive actions and ground-level feedback from businesses in Mumbai and Delhi till June 1 this year, however, does not take into account the impact of the goods and services tax launched a month later. The quality and pace of course correction on the GST in the coming months will determine if India can hold its 100th position or move up further. Talking up the Modi government’s approach, Mr. Jaitley sought to contrast the UPA era with the NDA’s tenure by saying that the ease of doing corruption has been replaced by the ease of doing business. While the government has valid reasons to be upbeat, it must not lose sight of the larger challenges. The enforcement of contracts now takes longer than it did 15 years ago, while procedures to start a business or secure a construction permit remain cumbersome. As the country’s largest urban agglomerations, Mumbai and Delhi cannot host the kind of large factories that India needs to generate adequate employment. It is critical that such procedural reforms reach the hinterland and a road map be drafted for the larger legislative changes needed in matters such as land acquisition.
  • Lastly, while foreign investors are important, they often take their cue from the mood of domestic businesses. Last week, for instance, Sunil Bharti Mittal said the ease of doing business remains a concern despite the government’s best intentions, and mooted a structured dialogue between India Inc. and policy-makers on the irritants to investment. The government, with great orators in its ranks, could perhaps be a better listener.