TB India - National Strategic Plan (NSP) 2017 - 2025, private sector care

National Strategic Plan (NSP) 2017 - 2025

The National Strategic Plan (NSP) 2017 - 2025 is the plan produced by the government of India (GoI) which sets out what the government believes is needed to eliminate TB in India. The NSP 2017 - 2025 describes the activities and interventions that the GoI believes will bring about significant change in the incidence, prevalence and mortality from TB. This is in addition to what is already going on in the country.

The NSP sets out the recommendations of the GoI. However, the rate at which these recommendations are implemented, will largely depend on the action taken by individual states.

Visions & Goals of the National Strategic Plan

TB multimedia campaign in India, INDIAVsTB encourages people to get tested for TB, an important part of the NS

TB multimedia campaign in India, INDIAVsTB encourages people to get tested for TB, an important part of the NSP.

The Vision is of a TB free India with zero deaths, disease and poverty due to tuberculosis

The Goal is to achieve a rapid decline in the burden of TB, mortality and morbidity, while working towards the elimination of TB in India by 2025.

The requirements for moving towards TB elimination in India have been arranged in four strategic areas of
Detect, Treat, Prevent & Build.There is also across all four areas, an overarching theme of the Private Sector. Another overarching theme is that of Key Populations.

Targets

The targets of the National Strategic Plan are set out as consisting of both outcome and impact indicators. There are also four main “thrust” or priority areas in the NSP which are:

  • Private sector engagement;
  • Plugging the “leak” from the TB care cascade (i.e. people with TB going missing from care);
  • Active case finding among key populations;
  • and for people in “high risk” groups, preventing the development of active TB in people with latent TB.

Another “thrust” area is that of the Programmatic Management of Drug Resistant TB (PMDT).

Detect

The aim is to detect all those people with drug sensitive TB as well as those with drug resistant TB. The emphasis is to be on reaching TB patients seeking care from private providers and also finding people with undiagnosed TB in “high risk” or key populations. This is to be done through:

  • Scaling up free, high sensitivity TB diagnostic tests such as CBNAAT;
  • Scaling up private provider engagement approaches;
  • Universal testing for drug resistant TB;
  • & Systematic screening of high risk populations.

Diagnosis

The Technical & Operational Guidelines for TB Control (TOG) describes how various tests should be used to diagnose anyone who has signs and symptoms suggesting that they might have TB. The tests to be used are sputum smear microscopy, chest X ray and the new CB-NAAT test. The CB-NAAT test is beginning to be made available throughout India. There is a diagram, or set of rules, which shows which tests should be used for different groups of people.

There is a further explanation on the page on Testing & diagnosis of TB in India.

Active case finding

The main objective of active case finding (ACF) is to detect TB cases early and to initiate treatment promptly. The NSP emphasizes the need to shift from passive case finding, which is waiting for people to seek care, to ACF which involves seeking out people in targeted groups.

Treat

Initiate and sustain all patients on appropriate anti-tb treatment wherever they seek care. Provide patient friendly systems and social support. This is to be done through:

  • Preventing the loss of TB cases in the cascade of care by providing support systems. The “cascade of care” means every step in the provision of treatment, from when it is first started, to the point at which the patient finishes their treatment and is cured of TB;
  • Providing free TB drugs for all patients with TB;
  • Provide daily TB drugs for all patients with TB and a rapid scale up of short course regimens for drug resistant TB. Provide treatment approaches guided by drug sensitivity testing.
  • Providing patient friendly adherence monitoring and social support in order to sustain TB treatment;
  • & The elimination of catastrophic costs by linking eligible TB patients with social welfare schemes including providing nutritional support.

At present TB drugs are free at government centres. The NSP plan is that eventually TB drugs will be available free from private centre pharmacies as well. Currently it is believed that only half of all TB patients make use of the free medicines. It is believed that making the TB drugs available in private hospitals:

"will also help remove the stigma among that section of society which is hesitant to approach government run centres for taking medicines"Jagdish Prasad, Director General of Health Services

Nutritional support for patients with TB

It has now been announced that patients with TB will receive R500 ($8) a month for food.

Under nutrition is a risk factor for TB in India. Under nutrition worsens the nutritional status, generating a vicious cycle which can lead to adverse outcomes during and after treatment for patients with active TB. This includes those with MDR-TB. So this payment is partially to ensure that patients with TB have adequate food. There is more about food and TB and malnutrition & TB.

“We need to understand when this scheme will be rolled out, how will the money be dispensed and if it includes all TB patients, including those seeking care in the private sector”. 1“A side effect of tuberculosis in India: crippling debt”,  https://www.reuters.com/article/us-india-health/a-side-effect-of-tuberculosis-in-india-crippling-debt-idUSKCN1G407M, Feb 20, 2018, Chapal Mehra, Survivors Against TB

It affects mainly poor and malnourished people, Finance Minister Arun Jaitley told parliament in his Feb 1 budget speech, a rare official acknowledgement of the scale and impact of the disease. In the 2018 budget Rs 600 crore was allocated for nutritional support for TB patients.

Prevent

Preventing the emergence of TB in susceptible populations. This is to be done through

Build

Build and strengthen relevant policies. Provide extra capacity for institutions and extra human resources capacity. This is to be done through:

  • Translating high level political commitment into action;
  • Restructuring the RNTCP and other institutional arrangements;
  • Building supportive structures for surveillance, research and innovations. Providing a range of interventions based on the local situation;
  • Scaling up technical assistance at national and state levels;
  • & Preventing the duplication of partners’ activities

Private Sector

Private provider engagement

At least half of those treated for TB in India first attend the largely unorganized and unregulated private sector. Patients from low income households will often lose several months of their income in the process of paying for inappropriate diagnostics and treatments before starting approved therapy.

Statewise proportion of notification of patients from private sector in 2016

Statewise proportion of notification of patients from private sector in 2016

Patients treated by private providers are not usually notified to the RNTCP, despite government orders to that effect. Patients cared for by private providers rarely receive sputum testing, and DST. Similarly, public health services such as surveillance, adherence monitoring, contact investigation, and outcome recording rarely reach privately treated patients.

A recent study of private doctors showed that only 29% of doctors had adequate knowledge of diagnosis, and only 29% knew a proper treatment regimen.2“To eradicate TB, many doctors must first learn how to diagnose it”, 2018, New Indian Express,
http://www.newindianexpress.com/thesundaystandard/2018/feb/03/to-eradicate-tb-many-doctors-must-first-learn-how-to-diagnose-it-1767881.html

There is now to be a major change in the way that the RNTCP engages with private providers. Partnership is to be the way forward. The previous approach was for private providers to direct people to the RNTCP to receive their care in the public sector. Now the approach is to be for the public sector RNTCP to work with the private sector, assisting the private sector to provide high quality care.

The new strategy for reaching patients in the private sector amounts to a total change in the way that the RNTCP has engaged private providers before. The new strategy is going to be systematic and large scale, rather than ad hoc and insignificant. Rather than the public sector competing with private providers the RNTCP will work with them to deliver quality STCI services to the entire population.

The aim is for the annual number of TB cases notified by private providers to increase ten fold, from 0.2 to 2 million annually. That is private providers should be providing 56% of total case notifications by 2020. For the first time there will also be a budget appropriate to both the size of the problem and the opportunity of private sector care.

The approach will be to firstly capture all TB patients by attracting notification from private providers and then work to improve the quality of care. Private providers will be provided with incentives.

Private provider incentives

Private providers will be provided with incentives (i.e. money) to encourage TB case notification, to ensure treatment adherence and also treatment completion. The money will be provided upon notification to the TB reporting software Nikshay. A direct beneficiary transfer (DBT) system will be used so that the money goes directly to the providers bank account.

The money for the Private Sector TB Care Provider is as follows:

  • Rs 250/- on notification of a TB case diagnosed as per Standards for TB Care in India (STCI)
  • Rs 250/- on completion of every month of treatment

Rs 500/- on completion of the entire course of TB treatment.

For notification and management of a drug sensitive patient over 6-9 months as per STCI, a private provider will be eligible to receive Rs 2750/-. For notification and correct management of a drug resistant case over 24 months as per STCI, a private provider will be eligible to receive Rs 6750/-.

Increasing support for patients seeking care in the private sector

Benefits given to TB patients in the public sector will be extended to patients in the private sector including social welfare support. Notification and adherence will be linked to integrated patient notification and social welfare payments. A system is to be put in place to provide money to patients for validated services via Aashar-enabled Direct Benefit Transfer (DBT).

Key Populations

Key populations are generally regarded as people who are socially vulnerable and people who are clinically high risk. They face barriers in accessing care. ACF in vulnerable groups is to be a focus of the NSP over the next five years. Some of the priority groups are as follows:

Vulnerable Groups for NSP 2017 - 2025
Priority Urban area Rural area Tribal area
1 Slum Difficult to reach villages Difficult to reach villages and hamlets
2 Prison inmates Mine workers Villages with known higher case load
3 Old Age homes Stone crusher workers Tribal school hostels
4 Construction site workers Population groups with known high malnutrition Areas with known high malnutrition
5 Refugee camps Populations known to drink raw milk Villages seeking care from traditional healers
6 Night shelters Populations known to eat uncooked meat Populations known to drink raw milk

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The Cost of the NSP 2017 - 2025

The cost of the NSP is going to depend on the pace of implementation of the strategy, the demand from states, and the availability of resources. It is expected that the cost of implementing the new NSP will be Rs 16,649 (USD 2,485 million). This would be a significant increase over the budget for the NSP 2012-2017.

How is the progress of the NSP to be monitored

A national level annual review of the NSP will be undertaken. There are also some main NSP impact indicators, & some main outcome indicators as well as some results indicators for PMDT.

Outcome Indicators for the National Strategic Plan 2017 - 2025

Outcome Indicators for NSP 2017 - 2025
Priority 2015 2020 2023 2025
1 Total TB patient notifications 1.74 mil 3.6 mil 2.7 mil 2 mil
2 Total patient notifications from private providers 0.19 mil 2 mil 1.5 mil 1.2 mil
3 No. of MDR/RR patients notified 28,096 92,000 69,000 55,000
4 Proportion of notified TB patients offered DST 25% 80% 98% 100%
5 Proportion of notified patients initiated on treatment 90% 95% 95% 95%
6 Treatment success rate among notified DSTB 75% 90% 92% 92%
7 Treatment success rate among notified DRTB 46% 65% 73% 75%
8 Proportion of identified targeted key affected population undergoing active case finding 0% 100% 100% 100%
9 Proportion of notified TB patients receiving financial support through DBT 0% 80% 90% 90%

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Results framework for PMDT indicators in the National Strategic Plan 2017 - 2025

Results Indicators for NSP 2017 - 2025
Indicator 2015 2017 2018 2020 2025
Proportion of notified patients offered DST 25% 50% 60% 80% 100%
No. of presumptive DRTB patients to be examined 341,395 600,000 700,000 1,100,000 1,500,000
No. of MDR/RR patients notified 29,057 53,460 66,000 92,000 55,000
No. of MDR/RR patients initiated on treatment 27,104 48,114 59,400 82,800 49,500
No. of XDR TB patients notified 2,340 2,406 2,970 4,140 2,475
No. of XDR TB patients initiated on treatment 2,127 2,165 2,673 3,726 2,228
Treatment success rate for MDR/RR TB 46% 48% 48% 65% 75%

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There are some more TB statistics for India.

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