Each year, World Tuberculosis (TB) Day is takes place on March 24 to raise public awareness about the health, social and economic consequences of TB, and to step up efforts to end the global TB epidemic. Vikas Panibatla, CEO, TB Alert India (TBAI) in an interaction with Viveka Roychowdhury highlights the initiatives taken by TBAI to help India in its fight against TB
Do you think India will be a ‘Tuberculosis Free India’ by 2025?
Under the present government, the elimination of TB by 2025 was announced. It is 5 years ahead of the global deadline of 2030. At the same, the National Strategic Plan (NSP) 2017-2025 framed by the Government of India, built on four major pillars of Detect-Treat-Prevent and Build, augmenting its efforts towards achieving the elimination goal.
Through new initiatives of community engagement, all molecular testing modalities and providing TB preventive treatment to the household contacts of Pulmonary TB patients are helping the unreached with immediate, correct TB testing and treatment services. While the country has earmarked the increased case notification, the COVID-19 pandemic and its impact on healthcare delivery had reversed the years of progress and TB in the specific context.
The majority of people who live in rural areas are most affected by it due to perceived community stigma and cultural hurdles for testing and treatment. Also, there is a major infrastructural gap in rural healthcare facilities.
While India achieved 83.7 per cent of new TB case notifications against estimated in 2019 but this dropped to 60.2 per cent in 2020 and 71.3 per cent in 2021 during the pandemic. Response of TB program to come on track is tremendous post-pandemic, while a target to achieve TB elimination by 2025, we all have to ensure at least eradicate by 2030.
What are the major obstacles observed by TBAI in India’s fight against TB to maintain sustained TB eradication efforts, as localised COVID waves seem the healthcare system on tender hooks?
There are multiple deeply entrenched barriers impending India’s fight against TB. There is also a persistent lack of awareness about the cause, risk factors, treatment, and prevention of pulmonary TB. It is most evident among people living in rural areas where raising awareness is crucial to reduce disease transmission.
As more than 40 per cent of the people in the country preferred to avail services from the private health sector, various TB program has amalgamated their efforts for meaningful engagement of private providers for TB in the country. This was made instrumental with the help of the Joint Effort for Elimination of TB (JEET) project initiated by TBAI, but sustaining the impact after project closure must be strengthened through constant efforts. Therefore, to tackle the TB in pandemic, a system-driven, and integrated health intervention is of paramount importance to engage the private health sector for sustained impact.
In the unprecedented pandemic time, civil society organisations/NGOs should come forward to supplement the national program, especially leveraging the support from local communities, and the private sector, building empowered TB champions for peer group patient support, etc. Perceived community stigma with cultural barriers to testing and treatment has been an issue with mass at large, with people preferring care by unqualified practitioners and ignoring or self-treating symptoms. There are also infrastructural deficits mainly in line with healthcare (medical facilities and ancillary infrastructure) and the inclusion of private-public partnerships for TB eradication in India.
There is a link between malnutrition and poor diets to TB incidence. How can this be handled at a policy level in a resource-constrained country like India?
We are a resource-constraint country, but the government of India has taken various initiatives to the eradication of TB. For eg. Nikshay Poshan Yojana, gives a Direct Bank Transfer of Rs 500 every month till the patient completes the treatment, for nutrition supplementation. Recently, the government also came up with a new initiative “Niksahy Mithra”, that enables people to adopt TB patients to provide support for their nutrition and medical needs. These two are the major initiatives by the government that address the stigma and motivate TB patients to complete their journey on a success note. This aspect is better taken at policy level. Proper nutrition counselling and demonstrations at facility level while giving the medicines and at follow up visits will be very helpful in reiterating the need for proper nutrition. We also need to prioritize the beneficiary group who are the most vulnerable in the India society so that it can have a long-term impact of nutritional intervention.
Does the recent budget allocate enough funding to control TB?
After devastating impact on India’s healthcare system due to Covid-19, experts expected more funding in the 2023 budget. India aspires to eliminate TB by 2025 through its national policies and programmes. Though it is a welcoming initiative, there is more work needs to be done to tackle TB by government through strategic partnership and collaboration with various stakeholders. More than 50 per cent of the TB patients rely on private hospitals for the treatment, therefore they need be engaged with the government policy makers. The operation of the health sector in both the public and commercial sectors urgently needs to be drastically improved. All TB patients must be effectively followed up on and under observation. Also, all TB patients require proper social, emotional, and nutritional assistance. Without a concerted funding to the control TB, the End TB strategy in India would only be a distant dream.
What are the initiatives from TBAI to reduce the burden of TB patients in India? How effective have they been over the past few years?
TBAI is operating in Andhra Pradesh, Delhi, Haryana, Punjab, Rajasthan and Telangana providing TB education session, testing, treatment care and support services in achieving National TB Elimination Program (NTEP). TBAI has been instrumental in bringing the community ownership for stigma free TB services. TBAI has trained more than 4000 members from local Community Structures such as women self-help groups, youth groups, labour unions, panchayat raj institution members for local action and reached more than 2.4 million people from different vulnerable communities such as industrial workers, tribal groups and urban slum dwellers with TB education sessions. More than 26500 TB symptomatic individuals facilitated for TB testing and of them 2800 found TB diagnosed and initiated on treatment.
In rural healthcare providers, 1635 informal providers trained and engaged in the project from 9 districts of Telangana and established a strong referral mechanism with NTEP services. As a result, 37775 individuals with TB like symptoms referred and of them 36976 tested for TB at NTEP facilities. 6141 All Forms TB patients diagnosed, notified under public sector through Nikshay. This project has addressed the key aspects of delay in TB testing and doctor shopping, and of course out of pocket expenses by the TB patients’ families during July 2018 to Dec 2021.
TBAI has contributed to 144911 new TB patients’ notifications to govt TB program and achieved a success rate of 85.5 per cent treatment outcome. In “Programmatic Management of TB Preventive Therapy”, also called Latent TB Infection program funded by GFATM, more than 3 lakh HHCs screened for TB symptoms and around 150000 eligible HHCs were initiated on TB preventive therapy. TBAI has impactful contribution in creating awareness, improving health seeking behaviour, building the capacities of local communities and health care providers, and pilot testing of newer initiatives to generate evidence for scale-up are the key thematic areas of TBAI.
TB patients and family members have to also battle social stigma, and this plays a major role in dropping off the treatment regime, leading to MDR TB. TBAI’s contribution in effective TB awareness and treatment for vulnerable communities.
There is a social stigma and prejudice around TB which has a serious tailback pushing the patients onto greater risk. Therefore, more local actions have been put in by TBAI. We conducted various capacity building sessions to community representatives such as PRI members, ward members, slum association members, and local community structure members. To make people aware about TB, community connect sessions were held among TB staff and community representatives. We have also Identified and trained more than 300 TB Champions to provide psychosocial and peer group counselling to TB patients while sharing the challenges they have faced and how did they address and overcome to win over TB. Patient Care Support Groups are formed with the support from NTEP staff at each facility (DMC/TU/PHC) as needed to reiterate on the importance of treatment adherence boosting their morale and self-esteem.
What are the strategies that could be employed to ensure access, adherence and adoption of preventive/prophylactic TB measures?
TBAI strengthened the private provider engagement both for TB care and preventive TB services. As rural India is highly deprived of healthcare infrastructure has huge base of informal providers like ASHA/AMM/AWM needs to be provides to sensitize the masses to initial/first point of care services. Additionally, meaningful engagement of community level structures such as women self-help groups, youth, labour unions, slum development societies, village organisations, PRI bodies, religious groups, workers unions etc. Therefore, there should be more synergetic contribution from NTEP and various and civil society partner organisations.
There should be more decentralised TB services to increase the access to TB testing and treatment. Build the community response to TB and strengthen peer support. We also need to train TB patient as a health volunteer for TB preventive therapy services to household contacts. There is an urgent need of equipping more health staff with uninterrupted delivery by making sufficient stock of testing kits and treatment regimens.
What is the plan for the next 2-3 years for TBAI, in terms of strategic partnerships for patient care and research, etc?
Over the next 2-3 years, TBAI will consolidate the learnings from previous and the current ongoing projects of TB in the country, to understand the leakages, bottlenecks, and navigate the solutions to better strategise its efforts for a greater impact. To achieve this, we’ll engage with key stake-holders such as private providers/associations, vulnerable community representatives/bodies, and other health and allied sectors.
We have worked with a wide range of stakeholders over the past years with national and local governments, multilateral and bilateral agencies, research institutions, universities, civil society organisations, and membership organisations. Strategic partnerships and collaborations are the cornerstone of progress. Like bringing more synergy between NTEP and Private health care delivery system for an impactful partnership. We’ve envisioned to bring a meaningful engagement of Panchayati Raj department and the village panchayat institutions. We will undertake operational research to illustrate good practices to scale up for a wider reach with TB testing and treatment services for hard-to-reach communities.
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