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In the last 15 days, Anisha Pando has not taken her tuberculosis medicines.
The 12-year-old from Mudgaon village in Sarguja, a remote district in Chhattisgarh, was diagnosed with tuberculosis in August last year.
Her village is 30 km from the nearest health centre run by the non-governmental organisation Sangwari, which has tied up with the government to provide free tuberculosis medicines.
But like several health centres across the country, it is running out of medicines. “Since the stock is limited, her father has to travel frequently to collect the medicines,” the centre’s nurse Dhanvantiri Porpe said. “He is a farmer. He cannot make so many trips. So she stopped her medication,” Porpe said.
For the second time in seven months, a drug stockout is hampering tuberculosis treatment across India with medication in short supply in several states. In August last year, too, a shortage of drugs used to treat patients infected by resistant strains of bacteria had left patients and doctors anxious.
This time, those affected are drug-sensitive patients like Pando, who respond well to the first line of tuberculosis drugs.
‘Supplies delayed’
On March 18, the Central TB division wrote to all states, asking them to locally procure drug-sensitive medicines for the next three months.
Usually, the Central Medical Services Society, the agency responsible for procuring drugs for the health ministry, floats a tender and finalises a supplier for all tuberculosis drugs and related diagnostics material. This supply is then distributed to each state. Such bulk procurements also allow the government to buy drugs at a cheaper rate.
“Central procurement of … [the drugs] is at an advanced stage. However, the supplies may get delayed due to unforeseen and extraneous circumstances,” the letter by the director- general of TB division, Dr Rajendra Joshi, stated.
Though states usually maintain a buffer stock of six months, most currently have medicines that will last less than a month.
Several state nodal officers are struggling to make arrangements to buy drugs on their own, especially with the model code of conduct in place for the Lok Sabha elections.
Earlier this week, Karnataka health minister Dinesh Gundu Rao wrote a letter to health minister Mansukh Mandaviya, flagging the shortfall in medicines. “Neither these medications are available in the quantities required by the state nor the procurement process can be hastened in view of both its manufacturing process as well as the prevailing model code of conduct,” Rao wrote. “While I do not wish to accuse the Union government of callousness, I have to point out that state support for TB patients has been jeopardised by this action of the Centre”.
With the supply from the government almost drying out, doctors are worried that patients may begin to drop out of treatment, said Dr Chetanya Malik, a physician who works with NGO Sangwari.
“Usually patients get medicines to last a month. Now they are expected to return every week or every few days,” said Malik. “Daily wagers cannot be expected to make so many rounds of health centres for medicines.”
In 2023, India notified 25.55 lakh new tuberculosis cases, including 1.43 lakh paediatric cases, data from the latest India TB report 2024 shows.
Mumbai-based health activist Ganesh Acharya said the absence of medicines risks turning more drug-sensitive patients into drug-resistant patients, who stop responding to the first line of drugs and require more potent drugs to kill the bacteria.
In 2023, 63,939 drug resistant patients were diagnosed in India. “This figure can increase if medicine supply is hampered so frequently,” Acharya said.
Dr Joshi, director general of Central TB Division, did not respond to calls and messages from Scroll over the drug shortage.
The January shortfall
In several states, as early as January, the supply of two drugs, both fixed dose combinations, began to dry out.
A fixed dose combination has two or more drugs combined in one tablet to reduce the number of medicines a patient has to take.
With tuberculosis requiring multiple medicines, a fixed dose combination makes it easier for patients to adhere to treatment and prevent them from dropping out.
Most Indian states currently have low stocks of 4-FDC, a fixed dose combination of isoniazid, rifampicin, pyrazinamide and ethambutol, which is given in the first two months of treatment to patients.
The second drug whose supply is a problem is 3-FDC, a fixed dose combination of three drugs – isoniazid, rifampicin, pyrazinamide.
Both these medicines are given to newly diagnosed TB patients.
In Chhattisgarh, there are 15,000 strips of 3-FDC, that will last a month. In some districts such as Sarguja, there is stock for only 13 more days, state officials said. “We are moving medicines to centres that do not have any stock,” a Chhattisgarh health officer, who requested not to be identified, told Scroll. “If we don’t get fresh stock in 15 days, there will be a total stockout in many centres,” the officer added.
Chhattisgarh had sent the Centre its requirements for TB medicines in mid-2023. “We did not initiate any procurement because the Centre does it. Now we have asked districts to procure at their level,” the officer said.
Maharashtra has 79,000 strips of 3-FDC, which will last another 13.5 days, an officer told Scroll on March 29. “We began the procurement process before the code of conduct set in. But that will take time,” the officer said. “Meanwhile, we have asked districts to buy medicines on their own from local suppliers.”
“Floating a tender may be difficult now since TB medicines are usually not procured at the state level,” a state officer from Chhattisgarh told Scroll.
The officer said all TB medicines are procured by the central government based on demands sent in advance by each state. The state is only tasked with distributing medicines to each government-run centre. Since the state does not usually procure, neither are “funds available to buy TB medicines at the state level” nor the tendering process is in place, the officer explained.
In Madhya Pradesh, state tuberculosis officer Dr Varsha Rai said there is a shortage of TB drugs but refused to elaborate on how long the stock will last. “We are in the process of procuring medicines through rate contracts,” she said.
Under a rate contract, no bids are called – a supplier is chosen and asked to provide the medicines.
In Punjab, state tuberculosis officer Dr Rajesh Bhaskar said they had anticipated a shortage several months ago and began to finalise suppliers. “There was a shortage of drug-resistant TB medicines last year from the Centre. To avoid that, we took out a rate contract several months ago so that we could place orders in case of an emergency,” he said.
According to data from the Central Medical Services Society, the central government called for a tender in September 2023 for 4-FDC and 3-FDC drugs.
The supply for the September tender is yet to begin. This year, the government called for an emergency tender for the drugs on March 8 and again on March 22.
The letter by the Central TB Division added that if districts or states are unable to procure and provide free drugs, patients can be reimbursed for the cost of drugs on a case-by-case basis.
Patients dropping out
In the absence of fixed dose combinations, several doctors are asking patients to take individual drugs for rifampicin, isoniazid, pyrazinamide and ethambutol. “We have switched some patients to individual drugs. But that means, they now have to take 8-9 tablets a day. Some may not prefer taking so many medicines,” said Malik.
This is just what happened in Sarguja.
Bijan Prasad Patra, 62, was put on the fixed dose combination, 3-FDC. From February, the medicines became scarce.
While individual tablets are available, he refuses to take them. “He is unable to take eight to nine tablets. He says it is difficult to eat food then. So he has stopped medication completely,” said nurse Dhanvantri Porpe.
In Odisha’s Khordha district, NGO Sahyog has written to the district administration to procure medicines. “There is absolutely no stock of adult drugs and some paediatric combinations,” said Vijaylaxmi Rautaraoi, who works with Sahyog.
Rautaraoi said patients have begun to default on their regimen since not everyone can afford to buy from chemists. “Last week was World TB Day. And the government is not able to even provide medicines. How will India eliminate TB by 2025 if this is the condition?”
This reporting was supported by a grant from the Thakur Family Foundation. Thakur Family Foundation has not exercised any editorial control over the contents of this article.
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