CHO-CH19: Patient Support | Knowledge Base

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Public Health Actions

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Public Health Action is conducted under the NTEP programme to support and prevent further health complications among TB patients after diagnosis.

Figure: Various activities under Public Health Action

Nutritional Support

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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.

Effects on disease	Increased severity of disease Increased risk of death
Effects on treatment	Delayed sputum conversion Risk factor for drug-induced hepatotoxicity Malabsorption of rifampicin Reversion of positive cultures in Multidrug-resistant (MDR) -TB
Effects on long-term outcomes	Increased rate of relapse
Effects on contacts	Increased incidence in undernourished contacts

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

Conducting an initial nutrition assessment of TB patients with further monitoring
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
Managing severe acute malnutrition according to national guidelines and WHO recommendations
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.
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

Assessment

Question 1	Answer 1	Answer 2	Answer 3	Answer 4	Correct Answer	Correct Explanation	Page id	Part of Pre-Test	Part of Post-Test
Undernutrition doesn’t affect the outcomes of TB.	True	False			2	Undernutrition affects the outcomes of TB in terms of treatment.

Psychosocial Support to TB Patients
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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)

Support for deaddiction

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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

Brief substance use counselling during the pre-treatment, treatment initiation and regular follow-up counselling sessions by the trained NTEP staff.
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.
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.
Referral to nearest Tobacco cessation clinics/ centres in the government facilities.
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

Assessment

Question	Answer 1	Answer 2	Answer 3	Answer 4	Correct answer	Correct explanation	Page id	Part of Pre-test	Part of Post-test
What service does the National Tobacco Quitline provide?	Telephonic counselling	Face-to-face counselling	None of the above	Both 1 & 2	1	National Tobacco Quitline: Telephonic counselling via the toll-free number in English and Hindi languages.		Yes	Yes

Support for Rehabitilation

Travel support for TB Patient

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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

Assessment

Question

Answer 1

Answer 2

Answer 3

Answer 4

Correct answer

Correct explanation

Page id

Part of Pre-test

Part of Post-test

How much amount is provided as transport allowance to tribal/ hilly area patients and their attendants during their TB treatment

Rs.250

Rs.500

Rs.750

Rs.1000

Rs. 750 is provided as transport allowance to Tribal/ hilly area patients and their attendants during their TB treatment.

Yes

Nikshay Poshan Yojana

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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

Question	Answer 1	Answer 2	Answer 3	Answer 4	Correct answer	Correct explanation
Only patients seeking treatment in public hospitals are eligible for Nikshay Poshan Yojana.	True	False			2	All patients who are receiving treatment from both public and private sectors and are notified on the Nikshay platform are eligible to receive the benefit.

Linkages to Social Welfare Schemes

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The government of India introduced Direct Benefit Transfer (DBT) to ensure that the benefits and subsidies are reaching the beneficiaries directly and to fasten the process. Through the process, money is directly transferred to the beneficiaries' bank account keeping the intermediary agencies and stakeholders only to manage the process of payment.

National TB Elimination Programme (NTEP) transfers all benefits to patients using the two systems:

Nikshay
Public Finance Management System (PFMS)

DBT Schemes available in the NTEP

Nikshay Poshan Yojana (NPY)

Objective: To provide nutritional support to TB patients at the time of notification and subsequently during the course of treatment.

Beneficiary: All unique TB patients notified on or after 1st April 2018 (including all existing TB patients under treatment for at least one month from this date).

Benefit Amount: Rs. 500 for a treatment month paid in instalments of up to Rs. 1000 as an advance.

Transport Support for TB patients in Notified Tribal Areas

Objective: To provide financial support as transport allowance for TB patients belonging to notified tribal areas (in addition to the nutritional support provided under NPY).

Beneficiary: All notified TB patients from notified tribal areas.

Benefit Amount: Rs. 750 as a one-time payment at the time of notification.

Incentives for Private Sector Providers and Informants

Objective: To provide financial incentives for notification and subsequent follow-up until completion of treatment of TB patients who are diagnosed/ treated by a private provider.

Beneficiary: Private providers (private practitioner, hospital, laboratory and chemist) who notify TB patients to NTEP on Nikshay.

Incentive Amount: Rs. 500 as a one-time payment on notification and Rs. 500 to a private practitioner or hospital for updating the patient’s treatment outcome.

Treatment Supporters’ Honorarium

Objective: To provide an honorarium to the treatment supporters for supporting TB patients.

Beneficiary: Community Treatment Supporters who support patients during treatment, leading to a successful outcome (cured or treatment completed).

Incentive Amount: Rs. 1,000 as a one-time payment on the update of outcome for drug-sensitive TB patients and Rs. 2,000 on completion of Intensive Phase (IP) and Rs. 3,000 on completion of Continuation Phase (CP) of treatment for drug-resistant TB patients.

Criteria/ Pre-requisites for Availing the Benefits in NTEP

All benefits are processed for the respective beneficiary base on the rules and eligibility criteria defined above except for the treatment supporter, which needs to be manually uploaded by the TB Unit (TU) level staff.
Beneficiary ID in Nikshay will be assigned to all patients which are unique. The benefits processed will be tracked under this ID. All beneficiaries need to register their bank details in Nikshay to enable DBT.

Treatment Supporter

A trained treatment supporter, who can be a health worker or community volunteer, will assist the patient to adhere to the drugs, provide counselling support, nutritional support, screen for adverse reactions, psycho-social support, comorbidity management and follow-up laboratory investigations.

The Treatment Support Honorarium is available as per the following eligibility:

The treatment Supporter must be registered in Nikshay and designated as the primary Treatment Supporter.
The linked patient must complete treatment or has to be cured.
The treatment Supporter should not be a salaried government employee.

Resources

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

Assessment

Question	Answer 1	Answer 2	Answer 3	Answer 4	Correct Answer	Correct Explanation
Only patients and treatment supporters seeking treatment in the public sector are eligible for DBT benefits.	True	False			2	Private providers are eligible for financial incentives for notification and subsequent follow-up until completion of treatment of TB patients who are diagnosed/ treated by them.

PMJAY

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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

Question	Answer 1	Answer 2	Answer 3	Answer 4	Correct answer	Correct explanation	Page id	Part of Pre-test	Part of Post-test
PM-JAY benefits can be redeemed only from government hospitals.	True	False			2	PM-JAY provides cashless & paperless benefits at public hospitals and empanelled private hospitals. It 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 not-for-profit providers.		Yes	Yes