Poorer populations are Two times more likely to have TB Three times less likely to access TB care Four times less likely to complete treatment Many times more likely to incur impoverishing payments for TB care

The vicious cycle of poverty and TB Coping strategies Decreased food intake Sell assets Borrowing Withdraw children from school Leave their families Delay seeking care Impact Loss of income Stigmatisation Homelessness Women children Coping strategies Poor housing Overcrowding Poor ventilation Malnutrition Risk behaviour

Poverty in India Widespread with the nation estimated to have a third of the world's poor. 42% of India falls below the international poverty line of US$ 1.25 a day (having reduced from 60% in 1981 (World Bank, 2005 estimate)) According to the criterion used by the Planning Commission of India 27.5% of the population was living below the poverty line in 2004–2005, down from 51.3% in 1977–1978, and 36% in Latest estimates by NCAER (National Council of Applied Economic Research), show that 52% of the Indian households earn less than Rs 90,000 ( US$ 2,025) annually (or less than US$3 PPP per person).

TB and Poverty in India  In India, it is estimated that in 2006 alone, TB has resulted in  Loss of 7.9 million DALYs (predominantly due the deaths)  An estimated economic loss of ~ US$ 23.7 billion to the Indian society ( Source: Mark Goodchild et al, IJTLD 2010 In press) TB leads to huge socio-economic burden due to  > 70% of the TB patients are in the economically productive age group (15-54 years)  At-least 2-3 months of work time lost per TB affected person  higher mortality among patients not treated or inadequately treated (95% of the economic loss is due to loss of life)

Key achievements 4: Economic Impact of RNTCP Economic impact study undertaken by the programme with the support of WHO-India shows that the RNTCP has also led to a gain in economic wellbeing of US$ 88.1 billion over Overall, the scale-up of TB control in India has been a very cost-effective mechanism to improve the health status of India’s population while the return on investment has been exceptional from the perspective of the Government and Donor agencies. This is reflected in an average cost of just US$ 26 per DALY gained from treatment and an average return of US$ 115 per dollar spent on TB control. Source: Mark Goodchild et al, IJTLD, In press

If we do business as usual, it might lead to violation of rights, alienation of patients, and reinforcement of stigma, thus undermining the improved outcomes that the community based model ostensibly aims to achieve. The absence of political will and resources to support meaningful community involvement underlies this fatal programmatic weakness. Between 2006 and 2009, except in the eastern Mediterranean region, regional budgets for advocacy, communication and social mobilisation have risen extremely slowly, if at all. Without increased resources, the rhetorical commitment to an enhanced role for communities carries little weight.

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