Tuberculosis (TB) continues to be a major public health challenge globally. India carries one-fourth of the global burden, with Mumbai being one of the high-burden cities. The Government of India has set the target of eliminating TB by 2025, five years ahead of the global Sustainable Development Goal target of 2030.
Persistent challenges hinder progress
Despite efforts to combat TB through various interventions in India, there are still gaps in the TB care cascade that affect the quality and effectiveness of care delivery. One of the major gaps is delay in diagnosis and care seeking. This is because of a lack of awareness, social stigma, and the high cost of treatment in the private sector.
Some challenges are demographic in nature. For example, in Mumbai, there is a robust laboratory network but limited avenues for point-of-care diagnosis. This especially delays diagnosis and further exacerbates the spread of TB in communities of slum dwellers and migrants.
“Mumbai faces a unique set of challenges due to its demographics and infrastructure. Poor nutritional status, high migration rates, and overcrowding lead to a disproportionate drug-sensitive and drug-resistant TB load. Additionally, the private sector in Mumbai lacks quality checks, which can result in inconsistent diagnosis and treatment outcomes,” explained Deepika Khaladkar, PATH Program Officer for TB working in Mumbai.
Moreover, there are several operational challenges, such as inconsistencies in sample tracking and logistics management and delays in updating results to Nikshay, which is a web-enabled patient management system for TB control under the National Tuberculosis Elimination Programme (NTEP).
Engaging the private sector and innovative technology
For almost a decade now, PATH has been helping India fight TB through greater engagement of doctors and patients. We supported the development of an award-winning project, Private Provider Interface Agency (PPIA) in Mumbai. PPIA partners with formal and informal private providers to notify the government of new cases, improves access to care by streamlining diagnosis and treatment processes and reducing financial barriers, and engages community-based partners and an innovative technology platform to improve case management and treatment success.
We have identified gaps across the TB care cascade that potentially could be bridged by existing provisions within Nikshay, linkages with external technologies, and greater uptake of government-approved and World Health Organization–recommended solutions.
With support from the Stop TB Partnership, our team in Mumbai promotes the use of digital approaches and solutions to benefit patients, lab technicians, treatment coordinators, and health care providers.
Reimagining TB care with digital tools
To address issues like social stigma, delays in health-seeking behavior, and lack of awareness, PATH encourages the use of the TB Aarogya Sathi application (app) among communities through organizing sensitization workshops, one-to-one patient interactions and distribution of information, education, and communication material.
This app augments the initiatives of the Indian government’s Central TB Division in proactively increasing awareness in the community about the disease- its screening, diagnosis and further management and treatment. Improved access to information through the TB Aarogya Sathi app can equip people to monitor their health, dispel myths, and access credible and accurate information.
To overcome inconsistencies in the tracking of TB test samples and other logistics like sample-related data management, we support the use of QR code technology. We have assisted in use of QR codes at health facilities and testing laboratories to digitally label the test samples and automate the process of tracking the transport of samples and data entry to Nikshay.
“We have received training to work with QR codes. This automation saves our time, reduces the possibility of human error, and has led to efficient operations, ultimately fast-tracking the diagnosis of TB in the patient,” said a lab technician from Mumbai.
In addition, PATH with support from Everwell is working toward linking diagnostic tests like CB-NAAT, Truenat, and computer-aided detection software with Nikshay to enable real-time access to test results on Nikshay for health care providers. This will not only eliminate reporting errors but will also facilitate faster diagnosis of TB and early initiation of treatment in TB patients.
To ensure that patients adhere to the treatment regimen, PATH promotes the use of 99DOTS Lite, which is a digital adherence technology already integrated with Nikshay. When patients receive their medication, they are encouraged to call a phone number that is mentioned on the 99DOTS Lite sticker pasted on the medication envelope. Any TB patient making a call to this number will have their adherence marked automatically on Nikshay. This approach gives patients the tools to take care of themselves. Additionally, this assists health care providers and treatment coordinators by giving them real-time information on patients that have missed taking medication.
Under the project, we are covering all aspects of a patient’s journey. From the presumptive stage (creating awareness though the TB Aarogya Sathi app) to diagnosis of TB (tracking transportation of test samples via QR codes) to treatment (through automation of test results on Nikshay) and patient follow-up for treatment adherence (99DOTS Lite as a digital adherence technology).
Sustainability is key
“We believe that no program can achieve impact if the interventions are not sustained. Since all the interventions implemented by PATH are already Nikshay integrated, the transition of activities to the National Tuberculosis Elimination Programme will be smooth,” said Mayank Sharma, Senior Program Officer, Health Systems Strengthening, PATH India.
“We also ensured that the actual service delivery is owned and maintained by the existing NTEP staff. This will ensure that our interventions are sustained post-project closure.”