India: PPM approach in Chennai increases case notification in private sector

The TB Free Chennai Initiative (TBFI) is a flagship program spearheaded by the Greater Chennai Corporation, supported by the National Institute for Research in TB (NIRT) and the Resource Group for Education and Advocacy for Community Health (REACH).

Under this initiative, REACH scaled up a multipronged approach with a special focus on presumptive TB patients seeking care in the private sector in Chennai city, which has 8.6 million residents with a third of them residing in the slums. These patients mostly belong to lower socio-economic strata and often seek care in the private sector for reasons such as easy access, proximity, convenient clinic timings, or confidentiality. Studies have shown that up to 85% of patients experiencing TB-related symptoms in urban areas first seek healthcare from private practitioners and about 50% ultimately get TB treatment outside the public TB program.

The target population experiences high delay in TB diagnosis, which could lead to worsening of the disease, increased transmission, bigger out-of-pocket payments for patients and lost work time with devastating consequences to urban slum dwellers. The economic impact of TB on patients and their families is compounded by these delays in addition to the actual diagnostic and treatment cost in the private sector. This population by virtue of seeking care in the private sector have limited access to the social welfare schemes of the government.

Some of the key barriers that the intervention aims to address include sub-standard diagnosis and treatment for people with TB; limited to no access to quality assured diagnostics and drug support, treatment adherence support and social welfare schemes of the government; lack of privacy and confidentiality. There is also an absence of a special support mechanism for women, who are particularly vulnerable due to stigma and poor nutrition.

Public-Private Mix: Engaging with the Private Health Sector

The intervention engages the entire spectrum of the private health sector through the establishment of 44 nodal centers (Nakshatra Centers – NC) in private hospitals. The centers offer quality assured diagnostics, treatment and support services to patients. Other private practitioners and community based TB finding activities in the area also have the option of referring presumptive TB patients to these centers, which act as Nodal centers for referrals.

Through the Nakshatra Centers, patients in the private sector have access to quality diagnostics for TB including chest X-rays and gene Xpert tests; daily regimen treatment as per STCI (Standards for TB Care in India); support for treatment adherence; and MDR-TB patients also get access to tertiary hospitals for initiation of treatment.

Trained Community Health Workers or TB Nanbans (TB friends in English) are available in NCs to facilitate case notification and linkage with the public health system. They support private practitioners with sputum collection and transportation, case notification and contact tracing. They also address patients’ issues and needs, promote adherence and provide holistic care to TB patients in the form of low-cost interventions such as counseling, home visits, nutrition support, risk assessment, patient education, de-addiction counseling, cough hygiene and overall lung health care.

In addition to private practitioners, REACH has also engaged private chemists and pharmacists to refer those with TB symptoms for testing and to also provide patient education. These pharmacists have also been linked to NCs expanding the scope for case finding and patient care.

The key components that were scaled up in this intervention include the provision of decentralized access to X-ray by partnering with a network of laboratories; the outreach and sensitization of chest physicians, general practitioners and specialty practitioners; the follow up of these doctors and private chemists and pharmacists on a regular basis through one to one visits.

Furthermore, a network of partnerships has been developed between patients, private providers, private hospitals, chemists, laboratories and community volunteers for a smoother coordination and to ensure the cascade of care to patients with presumptive and/or diagnosed TB. Mission hospitals and hospitals run by NGOs have also been engaged for this intervention.

Private practitioners have been provided with patient education materials and tools such as referral coupons. In addition, the Government of India has developed a portal of Nikshay to facilitate the notification of new TB patients under their care.

Between April 2017 and June 2018, 2669 private practitioners were mapped among whom 1812 were sensitized. More than 700 private practitioners, 60 private laboratories and 393 private Pharmacies were engaged.

During this period, 9964 referrals were received at the 44 Nakshatra Centers. Among these people with presumptive TB, 3857 received free chest x-rays and 6334 received free Gene Xpert tests. Out of the 9964 referrals, 3007 patients were diagnosed with TB out of which 1701 were bacteriologically positive. 2950 patients were initiated on treatment.

On comparing Q2 2017 with Q2 2018, referrals increased by 340% from 804 to 2737. Case detection (diagnosed as TB among referrals) increased by 260% from 330 to 868 and the microbiologically confirmed patients saw an increase of 240%. Private sector notifications in Chennai increased by more than 450% compared to 2015.

Continuing efforts to find the missing people with TB

In the near future, REACH has plans to adopt some additional interventions:

Skill Development Training Programs: As TB imposes an economic impact on patients and their families, efforts are being made to link patients to skill development programs. This will be beneficial for patients to reduce their economic hardships and create opportunities for them.

Corporate Hospital Programs: To reach out to patients seeking TB care at Corporate Hospitals, there are plans to provide support services like counseling, follow up phone call reminders for check-ups and TB education materials to increase adherence of patients. It is anticipated that these patients may be affluent and may not want the free TB services offered under private and public initiatives.

Special focus on Pediatricians: to improve diagnosis and management of childhood TB and to improve chemoprophylaxis for children less than 6 years old as per the National guidelines.

Diabetic screening: to ensure detection and linkage to diabetes management to ensure good treatment outcomes among TB patients.

Identification of at risk patients: targeted counseling for tobacco cessation during the course of TB treatment in the Nakshatra Centers.