The Importance of Implementation Strategy in Scaling Up Xpert MTB/RIF for Diagnosis of Tuberculosis in the Indian Health-Care System: A Transmission Model.
By Henrik Salje, Jason Andrews, Sarang Deo, Srinath Satyanarayana, Amanda Sun, Madhukar Pai, David Dowdy
PLoS Medicine | July 2014
DOI
doi.org/10.1371/journal.pmed.1001674
Citation
Salje, Henrik., Andrews, Jason., Deo, Sarang., Satyanarayana, Srinath., Sun, Amanda., Pai, Madhukar., Dowdy, David. The Importance of Implementation Strategy in Scaling Up Xpert MTB/RIF for Diagnosis of Tuberculosis in the Indian Health-Care System: A Transmission Model. PLoS Medicine doi.org/10.1371/journal.pmed.1001674.
Copyright
PLoS Medicine, 2014
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Abstract
India has announced a goal of universal access to quality tuberculosis (TB) diagnosis and treatment. A number of novel diagnostics could help meet this important goal. The rollout of one such diagnostic, Xpert MTB/RIF (Xpert) is being considered, but if Xpert is used mainly for people with HIV or high risk of multidrug-resistant TB (MDR-TB) in the public sector, population-level impact may be limited. We developed a model of TB transmission, care-seeking behavior, and diagnostic/treatment practices in India and explored the impact of six different rollout strategies. Providing Xpert to 40% of public-sector patients with HIV or prior TB treatment (similar to current national strategy) reduced TB incidence by 0.2% (95% uncertainty range [UR]: −1.4%, 1.7%) and MDR-TB incidence by 2.4% (95% UR: −5.2%, 9.1%) relative to existing practice but required 2,500 additional MDR-TB treatments and 60 four-module GeneXpert systems at maximum capacity. Further including 20% of unselected symptomatic individuals in the public sector required 700 systems and reduced incidence by 2.1% (95% UR: 0.5%, 3.9%); a similar approach involving qualified private providers (providers who have received at least some training in allopathic or non-allopathic medicine) reduced incidence by 6.0% (95% UR: 3.9%, 7.9%) with similar resource outlay, but only if high treatment success was assured. Engaging 20% of all private-sector providers (qualified and informal [providers with no formal medical training]) had the greatest impact (14.1% reduction, 95% UR: 10.6%, 16.9%), but required >2,200 systems and reliable treatment referral. Improving referrals from informal providers for smear-based diagnosis in the public sector (without Xpert rollout) had substantially greater impact (6.3% reduction) than Xpert scale-up within the public sector. These findings are subject to substantial uncertainty regarding private-sector treatment patterns, patient care-seeking behavior, symptoms, and infectiousness over time; these uncertainties should be addressed by future research. The impact of new diagnostics for TB control in India depends on implementation within the complex, fragmented health-care system. Transformative strategies will require private/informal-sector engagement, adequate referral systems, improved treatment quality, and substantial resources.

Sarang Deo is a Professor of Operations Management at the Indian School of Business (ISB). He also serves as the Executive Director of the ISB’s Max Institute of Healthcare Management, where he provides strategic leadership for ISB's healthcare initiatives through interdisciplinary research, education, and collaboration.

Professor Deo's research focuses on healthcare delivery systems, examining how operational decisions influence population-level health outcomes. His work spans a wide range of healthcare contexts, including influenza vaccine supply chains and ambulance diversion in the United States, HIV early infant diagnosis networks in sub-Saharan Africa, and formal and informal pathways for tuberculosis (TB) diagnosis and treatment in India. His recent research has focused on designing and evaluating healthcare delivery models, with a particular emphasis on digital health and the integration of artificial intelligence into healthcare systems.

He regularly collaborates with leading global health organisations, including the Gates Foundation, the Clinton Health Access Initiative (CHAI), and PATH. He currently serves on the World Health Organization's Strategic and Technical Advisory Group for Tuberculosis (STAG-TB) and the Working Group for Non-Technical Evaluation under the WHO Global Initiative on AI for Health (GI-AI4H).

Prior to joining ISB, Professor Deo was an Assistant Professor at the Kellogg School of Management. He holds a PhD from the UCLA Anderson School of Management, an MBA from the Indian Institute of Management Ahmedabad, and a BTech from the Indian Institute of Technology Bombay. Before entering academia, he worked as a management consultant with Accenture.

Professor Sarang Deo
Sarang Deo