DR-TB HIV Coordinator: Patient Support

Nutrition constitutes an important part of TB Treatment. Undernutrition increases the risk of Tuberculosis (TB), and in turn, TB can lead to malnutrition. It has been demonstrated that undernutrition is a risk factor for progression from TB infection to active TB disease, and undernutrition at the time of diagnosis of active TB is a predictor of increased risk of death and TB relapse. There is, as yet, little evidence showing that additional nutrition support improves TB-specific outcomes, but low body mass index, as well as lack of adequate weight gain during TB treatment, are associated with an increased risk of TB relapse and death.

The following table illustrates the effect of undernutrition on outcomes in TB.

The basic recommendations to address the nutritional needs of TB patients are discussed below.

1. Conducting an initial nutrition assessment of TB patients with further monitoring
2. Providing ongoing counselling for patients on their nutritional status; Diet for TB patients starting treatment should include: cereals (maize, rice, sorghum, millets, etc.), pulses (peas, beans, lentils, etc.), oil, sugar, salt, animal products (canned fish, beef and cheese, dried fish), and dried skimmed milk
3. Managing severe acute malnutrition according to national guidelines and WHO recommendations
4. Managing moderate undernutrition for TB patients who fail to regain normal Body Mass Index (BMI) after two months of TB treatment or appear to lose weight during TB treatment and evaluating for proper treatment adherence and other comorbidities. If indicated, these patients should be provided with locally available nutrient-rich or fortified supplementary foods.
5. Special categories of TB patients, such as:

• Children who are less than 5 years of age should be managed as any other children with moderate undernutrition.
• Pregnant women with active TB and patients with MDR-TB should be provided with locally available nutrient-rich or fortified supplementary foods.

     6. Micronutrient supplementation for all pregnant women as well as lactating women with active TB. These women should be provided with iron and folic acid and other vitamin and minerals to complement their maternal micronutrient needs. In situations when calcium intake is low, calcium supplementation is recommended as part of antenatal care.

To achieve the above objectives, the guidelines for nutrition for TB patients are available and a mobile application (N-TB) is available for decision-making on nutritional support for TB patients.            

Improving nutritional status at a population level is important for TB prevention which should be part of broader actions on social determinants. All efforts should be made to link TB patients for nutritional support which can be done through the existing public distribution system, local self-government or Non-governmental Organisations (NGOs)or donor agencies or through the corporate sector under Corporate Social Responsibility (CSR).

Resources

• Guideline: Nutritional Care and Support for Patients with Tuberculosis, WHO, 2013.
• Guidance Document: Nutritional Care and Support for Patients with Tuberculosis in India, MoHFW, WHO, CTD, 2017.
• Training Modules (1-4) For Programme Managers & Medical Officer NTEP, CTD, WHO, MoHFW, 2020.
• Guidelines for Programmatic Management of Drug-resistant Tuberculosis in India, MoHFW, WHO, 2021.

Assessment

Who can provide Psychosocial support?

Family Members, Peer groups, treatment support groups, TB Champions, Community Health Volunteers(CHVs) and NGOs can provide psychosocial support to TB patients and their families by:

• Building a strong sense of community
• Helping the patients to contact a health worker or visit a health facility
• Providing treatment support to take their drugs and finish their treatment. Family members, community-based volunteers and workers can be trained as treatment supporters by NGOs
• Facilitating patients to access DBT for nutritional support under NPY
• Helping TB patients with comorbidities to visit the referral facility for treatment
• Treatment adherence support through peer support and education and individual follow up
• Home-based palliative care for TB
• Awareness generation, providing right information, behaviour change communication and community mobilisation for reducing stigma and discrimination
• Facilitating patients to join yoga/meditation/exercise groups once the active phase is over
• Facilitating and arranging rehabilitative services for problems/disabilities in TB patients
• Social and livelihood support
• Food supplementation
• Income-generation activities(NGO can start or facilitate patients to join activities like candle making, making festival-related goods)
• Sensitising PRIs to engage TB patients(who can work) through the Mahatma Gandhi National Rural Employment Guarantee Scheme(MGNREGS)

Substance use has been one of the major reasons for non-adherence to TB treatment and therefore, the National TB Elimination Programme (NTEP) has implemented several initiatives for control and de-addiction of substance use in association with various other health programmes like the National Tobacco Control Programme (NTCP), Drug De-Addiction Programme (DDAP), etc.

NTEP has also included referral services to de-addiction facilities for TB patients as a part of the ‘Standards for TB Care in India (STCI)'.

Deaddiction Services and Linkages

1. Brief substance use counselling during the pre-treatment, treatment initiation and regular follow-up counselling sessions by the trained NTEP staff.
2. Referral to National Tobacco Quitline provides telephonic counselling via the toll-free number in English and Hindi languages 8 a.m. to 8 p.m. between Tuesday to Sunday.
3. Referral to mCessation Programme provides evidence-based behavioural change Short Text Messages (SMSs) in English and Hindi languages on mobile phones, which include health information on tobacco use hazards, tips on quitting, and encouragement for those attempting to do so.
4. Referral to nearest Tobacco cessation clinics/ centres in the government facilities.
5. Referral under the Drug De-Addiction Programme (DDAP) wherein affordable, easily accessible and evidence-based treatment for all substance use disorders are provided through the government health care facilities of the Ministry of Health and Family Welfare, viz., All India Institute of Medical Sciences (AIIMS), New Delhi; Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh; National Institute of Mental Health and Neuro-Sciences (NIMHANS), Bengaluru; Dr Ram Manohar Lohia (RML) Hospital, New Delhi; AIIMS, Bhubaneswar; and Central Institute of Psychiatry (CIP), Ranchi.

Resources

• National Strategic Plan 2017-2025 for TB Elimination in India, MoHFW, India, 2017.
• National Framework for Joint TB-tobacco Collaborative Activities, MoHFW, India, 2017.

Assessment

Eliminating the catastrophic expenditure on TB patients and their families has been an important goal of the World Health Organisation's (WHO’s) END TB strategy.

The National TB Elimination Programme (NTEP) has also attempted the same through various partnerships and one of the action plans under this strategy was to provide transport allowance to cover the TB treatment-related travel costs of the TB patients as well as their attendants.

Travel cost for Drug-resistant TB (DR-TB) patients

• Travel costs are reimbursed for DR-TB patients travelling to District or Nodal DR-TB Centre for initiation/ follow-ups/ adverse reaction management during the treatment, along with one accompanying person/ attendant.
• The reimbursement is as per actual cost per visit through public transport with a limit of up to Rs. 400 per visit within the district and up to Rs. 1000 per visit for outside district travel.

Travel cost for TB Patients in tribal/ hilly/ difficult areas

• TB Patients from tribal /hilly/difficult areas are provided with an aggregate amount of Rs. 750 as transport allowance to cover patients and the attendants' travel costs.
• Rs. 750 as a one-time payment at the time of noti­fication.

Travel cost for Presumptive TB patients to visit District TB Centres (DTC)/ collection centres for testing

• Presumptive TB patients travelling to DTC/ collection centre are reimbursed as per actual cost with public transport.

Resources

• Guidelines on Programmatic Management of Drug-resistant TB (PMDT) in India, 2021, CTD, MoHFW, India.
• Direct Benefi­t Transfer Manual for National Tuberculosis Elimination Programme. Central TB Division, Ministry of Health & Family Welfare, India, 2021.

Assessment

Nikshay Poshan Yojana (NPY) is one of the four initiative-based support schemes which provides financial support to TB patients for their nutrition. A financial incentive of Rs. 500 per month will be provided to patients on anti-TB treatment till the completion of treatment.

• All TB patients who are registered/ notified (from both public/ private sectors) on the Nikshay Portal on or after 1^st April 2018 are beneficiaries of the scheme.
• The incentive is paid in cash and will be deposited to the Aadhaar enabled bank account of the patient. In the case of paediatric TB patients, money will be deposited in parents'/ guardians’ accounts.
• The first instalment of Rs. 1000 total for the first 2 months is expected to be disbursed immediately after starting treatment. To ensure treatment adherence, after the first instalment, the conditionality of follow-up examination is applicable.
• Each month of treatment extension, Rs. 500 will be transferred to the patient's DBT account, till the treatment is continued.
• In some states, where the incentive is transferred in-kind, they should provide food baskets with a total value not less than the corresponding eligible benefit.

Figure: Aims of Nikshay Poshan Yojana

The health volunteer/ Treatment supporter, Multi-purpose Health worker in-charge, or the Senior Treatment Supervisor (STS), are responsible to collect the bank details of the patient from the field level and enter it on the Ni-kshay.

Resources

Nutritional Support DBT Scheme Details, CTD.

Direct Benefi­t Transfer Manual for National Tuberculosis Elimination Programme, CTD, 2020.

Guidelines for Programmatic Management of Drug-resistant TB in India, 2021.

Assessment

In the National Sample Survey Office (NSSO) 68th round 2011-2012, India was reported to have the highest out-of-pocket expense on healthcare, of which over 67% was spent on drugs. Recognising the importance of essential drugs being available and accessible to the general public, the Ministry of Health & Family Welfare, Govt. of India, implemented the Free Drugs Service Initiative (FDSI) under the National Health Mission (NHM) in 2015.

Objectives

• To ensure that a set of essential drugs is made available free of cost to all those who access public health care facilities.
• To reduce the Out-of-Pocket Expenses (OOPE) of patients to support their treatment and adherence to medication.

Under this initiative, provision for obtaining free of cost essential medicines is made available through public health facilities under the National Health Mission at Primary Health Centres (PHCs), Community Health Centres (CHCs), Sub Divisional Hospitals (SDH) and District Hospitals (DHs).

Under this scheme, National TB Elimination Programme (NTEP) recommended Fixed-Dose Combination (FDC) anti-TB medicines are also available for both paediatric and adult TB patients. While most of these medicines are procured centrally, few loose drugs, especially for prophylaxis, are allowed to be procured at the state or district level at times when central supply is short. 

NHM has dedicated funding for free drugs, and various levels, including Peripheral Health Institutions (PHI), are allotted preset budgets under this scheme. PHIs are supposed to procure essential drugs which are not supplied by the government-owned "General Medical Stores" from this budget. Although most of the drugs are readily provided to the PHIs, some subsidiary drugs and supplements, which are required in TB care, can be made available under this scheme. For example drugs required to treat minor adverse drug reactions, vitamins, protein supplements, expectorants, antitussives, etc. 

Resources

• Operational Guidelines - Free Drugs Service Initiative, MoHFW, GoI.

• National Strategic Plan for Tuberculosis Elimination 2017–2025, RNTCP, CTD, 2017.

• Essential Medicine List for SHC & PHC Level, Ayushman Bharat - Health and Wellness Centre, 2020.

Assessment

Figure: Components of Ayushman Bharat Yojana

Pradhan Mantri Jan Arogya Yojana (PM-JAY) is one of the two key components of the Ayushman Bharat Yojana launched by the Government of India as part of the National Health Policy 2017. It is one significant step toward achieving Universal Health Coverage (UHC) and Sustainable Development Goal - 3 (SDG3): Good health and well-being.

Aim

To provide health protection cover to poor and vulnerable families against financial risk arising from catastrophic health episodes.

Provisions

• Financial protection (Swasthya Suraksha) to 10.74 crore poor, deprived rural families and identified occupational categories of urban workers’ families as per the latest Socio-Economic Caste Census (SECC) data (approx. 50 crore beneficiaries). It will offer a benefit cover of Rs. 5,00,000 per family per year (on a family floater basis).
• Cover medical and hospitalisation expenses for almost all secondary care and most of the tertiary care procedures. PM-JAY has defined 1,350 medical packages covering surgery, medical and daycare treatments, including medicines, diagnostics and transport.
• To ensure that nobody is left out (especially girl child, women, children and the elderly), there will be no cap on family size and age.
• Cashless & paperless at public hospitals and empanelled private hospitals.
• Beneficiaries are not required to pay any charges for hospitalisation expenses.
• Benefit also includes pre and post-hospitalisation expenses.
• The scheme is entitlement based; the beneficiary is decided based on the family being figured in the SECC database.

Benefits for the Health Care System of the Country

• Helps to achieve UHC and SDG.
• Ensures improved access and affordability of quality secondary and tertiary care services through a combination of public hospitals and well-measured strategic purchasing of services in health care deficit areas from private care providers, especially the not-for-profit providers.
• Significantly reduces out-of-pocket expenditure for hospitalisation. Mitigates financial risk arising out of catastrophic health episodes and consequent impoverishment for poor and vulnerable families.
• Acts as a steward, align the growth of the private sector with public health goals.
• Promotes the use of evidence-based health care and cost control for improved health outcomes.
• Strengthens public health care systems through the infusion of insurance revenues.
• Enables the creation of new health infrastructure in rural, remote and under-served areas.
• Increases health expenditure by the government as a percentage of Gross Domestic Product (GDP).

Resource

• National Health Portal

Assessment