Impact of involvement of non-formal health providers on TB case notification among migrant slum-dwelling populations in Odisha, India

Barriers and facilitators to informal healthcare provider engagement in the national tuberculosis elimination program of India: An exploratory study from West Bengal

India has a high burden of Tuberculosis (TB), accounting for a significant portion of global cases. While efforts are being made to engage the formal private sector in the National TB Elimination Program (NTEP) of India, there remains a significant gap in addressing the engagement of Informal Healthcare Providers (IPs), who serve as the first point of contact for healthcare in many communities. Recognizing the increasing evidence of IPs' importance in TB care, it is crucial to enhance their engagement in the NTEP. Therefore, this study explored various factors influencing the engagement of IPs in the program. A qualitative study was conducted in West Bengal, India, involving 23 IPs and 11 Formal Providers (FPs) from different levels of the formal health system. Thematic analysis of the data was conducted following a six-step approach outlined by Braun and Clarke. Three overarching themes were identified in the analysis, encompassing barriers and facilitators to IPs' engagement in the NTEP. The first theme focused on IPs' position and capacity as care providers, highlighting their role as primary care providers and the trust and acceptance extended by the community. The second theme explored policy and system-level drivers and prohibitors, revealing barriers such as role ambiguity, competing tasks, and quality of care issues. Facilitators such as growing recognition of IPs' importance in the health system, an inclusive incentive system, and willingness to collaborate were also identified. The third theme focused on the relationship between the formal and informal systems, highlighting a need to strengthen the relationship between the two. This study sheds light on factors influencing the engagement of IPs in the NTEP of India. It emphasizes the need for role clarity, knowledge enhancement, and improved relationships between formal and informal systems. By addressing these factors, policymakers and stakeholders can strengthen the engagement of IPs in the NTEP.

Engaging the Private Health Service Delivery Sector for TB Care in India-Miles to Go!

More than half of the people with TB in India seek care from the private sector, where suboptimal quality of care is a concern. Significant progress has been made over the last five years to expand the coverage and to involve more private sector providers in TB care under the National TB Elimination Program (NTEP) in India. The objective of this review is to describe the major efforts and the progress made with regard to the engagement of the 'for-profit' private health service delivery sector for TB care in India, to critically discuss this, and to suggest the way forward. We described the recent efforts by the NTEP for private sector engagement based on the literature, including strategy documents, guidelines, annual reports, evaluation studies, and critically looked at the strategies against the vision of partnership. The NTEP has taken a variety of approaches, including education, regulation, provision of cost-free TB services, incentives, and partnership schemes to engage the private sector. As a result of all these interventions, private sector contribution has increased substantially, including TB notification, follow-up, and treatment success. However, these still fall short of achieving the set targets. Strategies were focused more towards the purchase of services rather than creating sustainable partnerships. There are no major strategies to engage the diverse set of providers, including informal health care providers and chemists, who are the first point of contact for a significant number of people with TB. India needs an integrated private sector engagement policy focusing on ensuring standards of TB care for every citizen. The NTEP should adopt an approach specifically tailored to the various categories of providers. For meaningful inclusion of the private sector, it is also essential to build understanding and generate data intelligence for better decision making, strengthen the platforms for engagement, and expand the social insurance coverage.

A systematic review and meta-analysis of active case finding for tuberculosis in India

Background

Active case finding (ACF) for tuberculosis (TB) is the cornerstone case-finding strategy in India's national TB policy. However, ACF strategies are highly diverse and pose implementation challenges in routine programming. We reviewed the literature to characterise ACF in India; assess the yield of ACF for different risk groups, screening locations, and screening criteria; and estimate losses to follow-up (LTFU) in screening and diagnosis.

Methods

We searched PubMed, EMBASE, Scopus, and the Cochrane library to identify studies with ACF for TB in India from November 2010 to December 2020. We calculated 1) weighted mean number needed to screen (NNS) stratified by risk group, screening location, and screening strategy; and 2) the proportion of screening and pre-diagnostic LTFU. We assessed risk of bias using the AXIS tool for cross-sectional studies.

Findings

Of 27,416 abstracts screened, we included 45 studies conducted in India. Most studies were from southern and western India and aimed to diagnose pulmonary TB at the primary health level in the public sector after screening. There was considerable heterogeneity in risk groups screened and ACF methodology across studies. Of the 17 risk groups identified, the lowest weighted mean NNS was seen in people with HIV (21, range 3-89, n=5), tribal populations (50, range 40-286, n=3), household contacts of people with TB (50, range 3-undefined, n=12), people with diabetes (65, range 21-undefined, n=3), and rural populations (131, range 23-737, n=5). ACF at facility-based screening (60, range 3-undefined, n=19) had lower weighted mean NNS than at other screening locations. Using the WHO symptom screen (135, 3-undefined, n=20) had lower weighted mean NNS than using criteria of abnormal chest x-ray or any symptom. Median screening and pre-diagnosis loss-to-follow-up was 6% (IQR 4.1%, 11.3%, range 0-32.5%, n=12) and 9.5% (IQR 2.4%, 34.4%, range 0-86.9%, n=27), respectively.

Interpretation

For ACF to be impactful in India, its design must be based on contextual understanding. The narrow evidence base available currently is insufficient for effectively targeting ACF programming in a large and diverse country. Achieving case-finding targets in India requires evidence-based ACF implementation.

Funding

WHO Global TB Programme.

What are the Tuberculosis Care Practices of Informal Healthcare Providers? A Cross-Sectional Study from Eastern India

India is the highest Tuberculosis (TB) burden country, accounting for an estimated 26 % of the global burden of disease. Systematic engagement of the private sector is a cornerstone of India's National Strategic Plan (NSP) for TB elimination (2017-2025). However, Informal Healthcare Providers (IPs), who are the first point of contact for a large number of TB patients, remain significantly underutilised in the National TB Elimination Program (NTEP) of India. Non-prioritisation of IPs has also resulted in a limited understanding of their TB care practices in the community. We, therefore, undertook a descriptive study to document IPs' TB care practices, primarily focusing on their approach to screening, diagnosis, treatment, and referral. This cross-sectional study was carried out from February to March 2020 in the Birbhum District of West Bengal, India. Interviews were conducted utilising the retrospective case study method. A total 203 IPs participated who reported seeing at least one confirmed TB patient in six months prior to the study. In that duration, IPs reported interacting with an average of five suspected TB cases, two of which were later confirmed as having TB. Antibiotic use was found to be common among IPs (highest 69% during the first visit); however, they were prescribed before the patient was suspected or confirmed as having TB. We noted the practice of prolonged treatment among IPs as patients were prescribed medicines until the second follow-up visit. Referral was the preferred TB case management approach among IPs, but delayed referral was observed, with only one-third (34%) of patients being referred to higher health facilities during their first visit. This study presents important findings on IPs' TB care practices which have consequences for achieving India's National Goal of TB elimination.

Stakeholders' perspectives and willingness to institutionalize linkages between the formal health system and informal healthcare providers in urban slums in southeast, Nigeria

BACKGROUND

The widely available informal healthcare providers (IHPs) present opportunities to improve access to appropriate essential health services in underserved urban areas in many low- and middle-income countries (LMICs). However, they are not formally linked to the formal health system. This study was conducted to explore the perspectives of key stakeholders about institutionalizing linkages between the formal health systems and IHPs, as a strategy for improving access to appropriate healthcare services in Nigeria.

METHODS

Data was collected from key stakeholders in the formal and informal health systems, whose functions cover the major slums in Enugu and Onitsha cities in southeast Nigeria. Key informant interviews (n = 43) were conducted using semi-structured interview guides among representatives from the formal and informal health sectors. Interview transcripts were read severally, and using thematic content analysis, recurrent themes were identified and used for a narrative synthesis.

RESULTS

Although the dominant view among respondents is that formalization of linkages between IHPs and the formal health system will likely create synergy and quality improvement in health service delivery, anxieties and defensive pessimism were equally expressed. On the one hand, formal sector respondents are pessimistic about limited skills, poor quality of care, questionable recognition, and the enormous challenges of managing a pluralistic health system. Conversely, the informal sector pessimists expressed uncertainty about the outcomes of a government-led supervision and the potential negative impact on their practice. Some of the proposed strategies for institutionalizing linkages between the two health sub-systems include: sensitizing relevant policymakers and gatekeepers to the necessity of pluralistic healthcare; mapping and documenting of informal providers and respective service their areas for registration and accreditation, among others. Perceived threats to institutionalizing these linkages include: weak supervision and monitoring of informal providers by the State Ministry of Health due to lack of funds for logistics; poor data reporting and late referrals from informal providers; lack of referral feedback from formal to informal providers, among others.

CONCLUSIONS

Opportunities and constraints to institutionalize linkages between the formal health system and IHPs exist in Nigeria. However, there is a need to design an inclusive system that ensures tolerance, dignity, and mutual learning for all stakeholders in the country and in other LMICs.

Intervention to improve diarrhea related knowledge and practices among informal healthcare providers in slums of Kolkata

Background

In the densely populated slums of Kolkata, informal healthcare providers’ (IHP) diarrhea-related knowledge and rationality of practices should be improved to reduce risk of adverse outcome, expenditure, and antimicrobial resistance.

Methods

A multicomponent intervention was conducted among 140 representative IHPs in the slums of 8 wards in Kolkata to assess its impact on their diarrhea-related knowledge and practice. Six intervention modules in local languages were provided (1 per month) with baseline (N = 140) and postintervention (N = 124) evaluation.

Results

Mean overall (61.1 to 69.3; P < .0001) and domain-specific knowledge scores for etiology/spread (5.4 to 8.1; P < .0001), management (6.4 to 7.2; P < .0001), and oral rehydration solution ([ORS] 5.7 to 6.5; P < .0001) increased significantly (at α = 0.05) after intervention and were well retained. Impact on knowledge regarding etiology/spread (adjusted odds ratio [aOR] = 5.6; P < .0001), cholera (aOR = 2.0; P = .0041), management (aOR = 3.1; P < .0001), ORS (aOR = 2.3; P = .0008), and overall (aOR = 4.3; P < .0001) were significant. Intervention worked better for IHPs who practiced for ≥10 years (aOR = 3.2; P < .0001), untrained IHPs (aOR = 4.8; P < .0001), and pharmacists (aOR = 8.3; P < .0001). Irrational practices like empirical antibiotic use for every cholera case (aOR = 0.3; P < .0001) and investigation for every diarrhea case (aOR = 0.4; P = .0003) were reduced. Rationality of testing (aOR = 4.2; P < .0001) and antibiotic use (aOR = 1.8; P = .0487) improved.

Conclusions

Multicomponent educational intervention resulted in sustainable improvement in diarrhea-related knowledge and practices among IHPs in slums of Kolkata. Policy implications should be advocated along with implementation and scale-up.

Role of informal healthcare providers in tuberculosis care in low- and middle-income countries: A systematic scoping review

Achieving targets set in the End TB Strategy is still a distant goal for many Low- and Middle-Income Countries (LMICs). The importance of strengthening public-private partnership by engaging all identified providers in Tuberculosis (TB) care has long been advocated in global TB policies and strategies. However, Informal Healthcare Providers (IPs) are not yet prioritised and engaged in National Tuberculosis Programs (NTPs) globally. There exists a substantial body of evidence that confirms an important contribution of IPs in TB care. A systematic understanding of their role is necessary to ascertain their potential in improving TB care in LMICs. The purpose of this review is to scope the role of IPs in TB care. The scoping review was guided by a framework developed by the Joanna Briggs Institute. An electronic search of literature was conducted in MEDLINE, EMBASE, SCOPUS, Global Health, CINAHL, and Web of Science. Of a total 5234 records identified and retrieved, 92 full-text articles were screened, of which 13 were included in the final review. An increasing trend was observed in publication over time, with most published between 2010–2019. In 60% of the articles, NTPs were mentioned as a collaborator in the study. For detection and diagnosis, IPs were primarily involved in identifying and referring patients. Administering DOT (Directly Observed Treatment) to the patient was the major task assigned to IPs for treatment and support. There is a paucity of evidence on prevention, as only one study involved IPs to perform this role. Traditional health providers were the most commonly featured, but there was not much variation in the role by provider type. All studies reported a positive role of IPs in improving TB care outcomes. This review demonstrates that IPs can be successfully engaged in various roles in TB care with appropriate support and training. Their contribution can support countries to achieve their national and global targets if prioritized in National TB Programs.

Engaging Informal Private Health Care Providers for TB Case Detection: Experiences from RIPEND Project in India

Background

Informal (unqualified) health care providers are an important source of medical care for persons with presumptive TB (PPTB) in India. A project (titled RIPEND) was implemented to engage informal providers for the identification of PPTBs and TB patients in 4 districts of Telangana State, India, during October 2018-December 2019 project period. Engagement involved sensitizing the informal providers about TB, providing them financial incentives to identify PPTBs, and linking these PPTBs to diagnostic and treatment services provided by the Government of India's National TB Elimination Programme.

Objectives

To describe (a) the characteristics of the informal providers, along with their self-reported practices on TB diagnosis, treatment, and challenges encountered by the RIPEND project staff in engaging them in the project and (b) the outputs and outcomes of this engagement.

Methods

We used a combination of one-on-one interviews with informal providers, group interviews with RIPEND project staff, and secondary analysis of data available within the project's recording and reporting systems.

Results

A total of 555 informal providers were actively engaged under the project. The majority (87%) had a nonmedicine-related graduate degree and had been providing medical care for more than 10 years. Most (95%) were aware that a cough for 2 weeks or more is a symptom of pulmonary TB and that such patients should be referred for sputum-smear microscopy at a government health facility. Challenges in engaging the informal providers included motivating them to participate in the study, suboptimal mobile usage for referral services, and delays in providing financial incentives to them for referring PPTBs. During the project period (October 2018-December 2019), 8342 PPTBs were identified of which 1003 TB patients were detected and linked to TB treatment services.

Conclusion

This project showed that engaging informal providers is feasible and that a large number of PPTB and TB patients can be identified through this effort. The Government of India should consider engaging informal providers for the early diagnosis of TB to reduce the missing TB cases in the country.

Social determinants of tuberculosis: context, framework, and the way forward to ending TB in India

INTRODUCTION

Social determinants are involved in the causation of TB and its adverse outcomes. This review was conducted to evolve a framework for action on social determinants with special reference to India in the context of the new END TB strategy.

AREAS COVERED

We reviewed the social context of TB in India as a neglected disease of the poor, its emergence in epidemic form in the colonial period, and the factors that resulted in its perpetuation and expansion in post-independence India. We examined the role of social determinants in two key pathways - the pathway of TB causation and its outcomes, and the care cascade for patients with TB, and its consequences. We reviewed the most important social determinants of TB including poverty, membership of certain castes and indigenous population, undernutrition and poor access to healthcare, especially in rural areas.

EXPERT OPINION

We suggest that TB elimination will require an optimal mix of enhanced biomedical and social interventions. TB elimination strategy in India needs a pro-poor model of patient - centered care inclusive of nutritional, psycho-social and financial support, universal health coverage, and social protection; and convergence with multi-sectoral efforts to address poverty, undernutrition, unsafe housing, and indoor pollution.

Slums, Space, and State of Health-A Link between Settlement Morphology and Health Data

Approximately 1 billion slum dwellers worldwide are exposed to increased health risks due to their spatial environment. Recent studies have therefore called for the spatial environment to be introduced as a separate dimension in medical studies. Hence, this study investigates how and on which spatial scale relationships between the settlement morphology and the health status of the inhabitants can be identified. To this end, we summarize the current literature on the identification of slums from a geographical perspective and review the current literature on slums and health of the last five years (376 studies) focusing on the considered scales in the studies. We show that the majority of medical studies are restricted to certain geographical regions. It is desirable that the number of studies be adapted to the number of the respective population. On the basis of these studies, we develop a framework to investigate the relationship between space and health. Finally, we apply our methodology to investigate the relationship between the prevalence of slums and different health metrics using data of the global burden of diseases for different prefectures in Brazil on a subnational level.

Performance of revised national tuberculosis control program in Bihar: A situational analysis

Background:

Monitoring of a program is a continuous assessment of certain key indicators of it through periodic reports. The efficiency of a health program is assessed by comparing its achievements with the expectations.

Methods:

The study was conducted based on the annual TB report of India for the year 2018 in order to monitor (Revised National Tuberculosis Control Program) RNTCP performance in the Bihar State and its various districts.

Results:

Case notification rate of various districts Bihar was far below the national average of 138 per lakh. Considering treatment initiation, the performance of various districts of Bihar were less than national figures (79.0%). In newly diagnosed TB cases, the treatment success rate of Bihar was 73%. This performance was more compared to Uttar Pradesh (66.0%) but less compared to Jharkhand (92.0%), West Bengal (88.0%), and national data (79.5%). Considering human resources, the total human resources in the states of Bihar (61.9%) and Jharkhand (58.3%) were similar. However, in Bihar, there was a vast shortage of ground-level staff [i.e. (senior treatment supervisor) STS, (senior TB lab supervisor) STLS, (public-private mix) PPM Co-ordinator, and (TB health visitor) TBHV)].

Conclusion:

It was found that Bihar was one of the less performing states in RNTCP with a vast shortage of ground-level staff and low overall treatment success rate compared to its neighboring states. Stringent monitoring and evaluation in every step of the program implementation should be done in order to improve RNTCP performance in Bihar.

"Is there a difference in treatment outcome of tuberculosis patients: Rural Healthcare Providers versus Community Health Workers?"

Introduction:

Rural healthcare providers (RHCPs) are the first point of contact for majority of patients in rural parts of India. A total of 75 RHCPs were trained and engaged in Hazaribagh to identify presumptive tuberculosis (TB) patients (PrTBPs) and refer them for diagnosis. Patients diagnosed with TB were initiated on directly observed treatment short course (DOTS) under the programme. Based on patients' choice, the treatment providers were either RHCPs or community health workers (CHWs). In this paper, we aim to compare the treatment outcomes of TB patients who received DOTS from RHCPs with CHWs.

Method:

This is a retrospective cohort study using secondary data routinely collected through project and Revised National TB Control Programme.

Results:

Over the period of 24 months, 57 RHCPs continued to be engaged with project and a total of 382 referrals were made out of which 72 (19%) were diagnosed with TB. Based on choice made, 40 (55%) of TB patients chose RHCPs and 32 (45%) CHWs as their treatment provider. The mean successful treatment completion rate was 87% in the RHCP group compared with 81% for CHWs (P value 0.464). The percentages of unsuccessful outcomes were similar for both groups.

Conclusions:

Our study demonstrates the process to engage RHCPs in TB prevention and care. The study highlights community preference for RHCPs as DOT provider who can produce similar TB treatment success rates as that of CHWs identified by programme.