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Category: Policy watch

  • Synergistic effect of State Technical Support Unit (STSU) and Patient Provider Support Agency (PPSA) in Improving quality of TB care for patients notified in Private in Bihar during 2021 to 2024

    Abstract:   India is one of the high burden countries that accounts for 26% of TB disease burden, 27% of mortality due to TB and 26% of drug-resistant TB (DRTB) globally. To reduce the disease burden and mortality, the ongoing National Tuberculosis Control Programme has been restructured to include newer diagnostic algorithm, addressing the gaps and delays across TB care cascade.  To accelerate the activities and give momentum, patient provider support agency (PPSA) was entrusted to promote private sector TB notification in Nikshay. The purpose was to decentralise the services to private healthcare services and to trace the missing cases and provide timely public health actions like drug susceptibility test (DST), drug adherence, comorbidity testing and contact tracing.  PPSAs have been instrumental in increasing notification in Nikshay. This was possible due to synergistic effect of State Technical Support Units (STSU) and PPSAs working together for improving quality of services accessible and available to TB patients notified in private sector. Another key outcome is increase in treatment success rate (TSR) which cumulatively hovers around 87% and adds to the overall TSR of the notified TB patients. Decrease in death trend among TB patients notified in private is an important quality indicator that is in sync with target set with National Strategic Plan to reduce mortality due to TB. 87% of Private sector notified patients know their diabetes status and 5% have been found to be diabetic who have been put on differentiated TB care as per programme norms.

    STSUs role in coming years shall focus on ensuring notification of cases take place within one week of diagnosis, timely NAAT (preferably within one week of diagnosis)

    Introduction: India is one of the high burden countries that accounts for 26% of TB disease burden, 27% of mortality due to TB and 26% of drug-resistant TB (DRTB) globally. To reduce the disease burden and mortality, the ongoing National Tuberculosis Control Programme has been restructured to include newer diagnostic algorithm, addressing the gaps and delays across TB care cascade. For this, National Strategic Plan 2017-2025 was framed based on the principles of detect, treat, prevent and build. The purpose was to detect cases early and treat them on time to reduce the spread of disease in the community.

    The Global call to end TB by 2035 was duly acknowledged in the SDG that set the time-line for 2030. Govt. of India accelerated the fight against TB and announced to make India TB Free by 2025. The ongoing programme was renamed as National TB Elimination Programme that set target to reduce TB notification rate to 44 per lakh by 2025.

    To accelerate the activities and give momentum, patient provider support agency (PPSA) was entrusted to promote private sector TB notification in Nikshay. The purpose was to decentralise the services to private healthcare services and to trace the missing cases and provide timely public health actions like drug susceptibility test (DST), drug adherence, comorbidity testing and contact tracing.

    Methods: Nikshay based TB notification data for patients notified in Bihar by “diagnosing facility” and “notification date” were taken for the period of 2021 to 2024 for cross sectional study. Data was analysed on excel to show the trends and progression for patients notified in private and its impact on total notification.

    Result:

    1. The private sector notification increased by 61% from 2021 to 2024 whereas public sector notification increased by 45% during the same period. Thus, private sector notification has cascading effect in increasing total notification by 55% during 2021 to 2024.
    2. Cumulative Treatment Success Rate (TSR) for all TB patients notified during 2021 – 2023 is 84%. During the same period TSR for patients notified in private sector is 87%.
    3. Death among patients notified in private have decreased from 5% to 1% from 2021 to 2024.
    4. During the period 2021 to 2024, out of 399124 notified TB patients, 359965 (90%) of the patients know their HIV status. 0.7% were found reactive during Point of Care test.
    5. Among 399124 notified in private during 2021 to 2024, 345250(87%) know their diabetes status, out of which 18758 (5%) were found to be diabetic.
      YearTB Notification based on Diagnosing Facility by Notification dateIncremental growth from previous year (%)Contribution of private sector in total notification (%)
    PRIVATEPublicGrand TotalPRIVATEPublicGrand Total
    20217543456852132286   57%
    2022920346999316202722%23%22%57%
    20231097467769918744519%11%16%59%
    20241219108269020460011%6%9%60%
    Grand Total399124287234686358   58%
    Diabetes testing status among notified TB patients
    YearNotification (Pvt)DiabeticNon-diabeticWho know their Diabetic status%Who know their Diabetic status% Diabetic detected among notified TB cases
    2021754343873633476722089%5%
    2022920344118754537957186%4%
    20231097465430883309376085%5%
    202412191053779932210469986%4%
    Grand Total3991241879832645234525087%5%
    HIV testing status among notified TB patients
    YearNotification (Pvt)Non-ReactivePositiveReactive%Who know their HIV status% who were either reactive or positive
    2021754346946426617793%0.6%
    2022920348276149925591%0.8%
    20231097469679765822589%0.8%
    202412191010806757522189%0.7%
    Grand Total399124357089199887890%0.7%

    Discussion: The genesis of PPSA goes back to a pilot project that was rolled out in 2014-2017 where public private interface agency (PPIA) acted as a connecting link between the Govt. health system, private providers and patients. The project was funded by Bill and Melinda Gates Foundation. The project was instrumental in providing support to the TB patients who were accessing private health system. The learnings of the project were scaled up across the country as Joint Effort to Eliminate TB (JEET). This was further modified to engage patient provider support agency (PPSA) as an intermediary to ensure TB care cascade is followed and quality services are made available to patients accessing private healthcare system. The PPSA is an arrangement under “Contract for Services”.

    To support the functioning of PPSAs, State Technical Support Units (STSUs) have been created in nine focussed states namely Bihar, Uttar Pradesh, Madhya Pradesh, Maharashtra, Karnataka, Tamil Nadu, Rajasthan and Assam and West Bengal. In Bihar, STSU started functioning from May 2022. The STSU was formed to address the concerns of PPSA agency, build their capacities and support them in adoption of Standards of TB care by private practitioners. STSU played a pivotal role in follow-up for NAAT testing, comorbidity testing, timely direct benefit transfer under nutritional support to beneficiaries. STSU supported in on-boarding of PPSA team, training, handholding support during supportive supervision visits, meeting district and State chapters of private medical association like IMA. This has resulted in better output and outcome that is reflected in percentage incremental growth in notification in double digits when compared with previous years.

    PPSAs have been instrumental in increasing notification in Nikshay. This was possible due to synergistic effect of State Technical Support Units (STSU) and PPSAs working together for improving quality of services accessible and available to TB patients notified in private sector. Another key outcome is increase in treatment success rate (TSR) which cumulatively hovers around 87% and adds to the overall TSR of the notified TB patients. Decrease in death trend among TB patients notified in private is an important quality indicator that is in sync with target set with National Strategic Plan to reduce mortality due to TB. 87% of Private sector notified patients know their diabetes status and 5% have been found to be diabetic who have been put on differentiated TB care as per programme norms.

    To sustain the momentum of ever-increasing notification, quarterly review meeting is conducted by STSU to assess the progress and suggest corrective measures. The efforts of Bihar were recognised by Central TB division where Bihar received first prize in category for highest incremental growth. Inspite of skewed availability of cartridge and chips, the NAAT testing was comparatively better than other States. To further leverage the efforts, Bihar has decided to roll out PPSAs in all 38 districts from 2025 onwards. The contract with the eligible partners has been signed and are operational since 2025.

    Conclusion: To further support the private sector notification and minimize the gaps in care cascade the role of STSU is undisputably needed and shall be continued till the notification trends are down the epidemiological curve. As of now, Bihar has achieved only 81% of the targets given for private sector TB notification. In 2024, Bihar registered 158 new case notification per lakh which is lower than the national average of 178 per lakh reported in India TB report 2024. STSUs role in coming years shall focus on ensuring notification of cases take place within one week of diagnosis, timely NAAT (preferably within one week of diagnosis)

  • Transborder migration and its consequences discussed in the light of 104 Indians deported from USA for illegal immigration

    Illegal immigration is often dealt with strenuous actions by the immigrant country but it raises various interconnected issues of mental agony, demeaning of human dignity and far reaching psycho social consequences. However, under international law and domestic laws certain conditions have been laid out where such illegal migration without proper document is allowed. Some of the commonly migration ground under emergency is asylum, refugee, threat of hostility and danger to life.

    But crossing border of a country illegally by adopting unfair means knowingly in pursuit of better economic pursuit is often not considered in good spirit. Various countries have time to time raised voice against such illegal migrants and it more so often become political agenda where natives support such moves. In India too, there is often dilemma on how to deal with Rohingya migrants who have inhabited illegally. In recent developments, Trump administration has deported around 104 Indians who have entered USA through porous borders and were caught by US Police. These people have illegally entered USA by paying huge amounts to travel agents who have misguided them to take this illegal routes.

    It is important to discuss the manner in which people have been migrating illegally and using various transits before reaching final destination. One of the famous transit countries is Indonesia for illegal migration to Australia. Australia Government’s policy is very strict to curb such illegal migration. O’Keefe v Calwell is a famous case where the Dutch lady was evacuated to Australia during World War II but was denied asylum and deportation order was issued in 1949. Though, she married Australian citizen and had a child subsequently but was directed to leave the country along with her child. She fought her case and got mass public support and the Court gave judgement in her favour.

    In another matter called MV Tampa case where Australian Government strongly opposed entry of distressed Norwegian Ship carrying refugees to enter their territory despite of international manoeuvre and intervention of international agencies. Finally, they were deported to Nauru Islands as Indonesia refused to accept them and there was constant pressure by Norway Government. The Australians supported the Govt. move but internationally the move was criticised. In Soering vs. UK and Chahal vs. UK, European Court of Human Rights have held that deportation cannot be granted if there is fear of ill human torture or fear of death.

    Ground of asylum for better future, job prospect and better economic pursuit has not been accepted as plea for waiver from deportation. However, Article 5 of International Covenant on Economic, Cultural and Social Rights endorses “No restriction upon or derogation from any of the fundamental human rights recognized or existing in any country in virtue of law, conventions, regulations or custom shall be admitted on the pretext that the present Covenant does not recognize such rights or that it recognizes them to a lesser extent.”  The question is whether such act of US Government is valid by deporting them to India? Second, whether the manner in which they were sent was justified and in line with protection of human dignity? What could have been alternative ways to handle such situation?

    As per US stand, the Govt. of India was informed of such illegal migration and list of citizens were shared to India. India should have acted promptly to take responsibility of its citizens who were in distress and were in need of support. India’s response was bit delayed. Second, US would have consulted Indian Government before sending these people back to India. The most painful part is the manner in which these people were deported to India in military aircraft. All people were handcuffed. The people in India are not very comfortable with this. There were discussions in Parliament and various political leaders across parties have raised their opinion on how it could have been done in better way. It certainly led to human rights violations.

    In Hirsi Jamaa vs. Italy case, the words of Justice Blackmun are so inspiring that they should not be forgotten. Refugees attempting to escape Africa do not claim a right of admission to Europe. They demand only that Europe, the cradle of human rights idealism and the birthplace of the rule of law, cease closing its doors to people in despair who have fled from arbitrariness and brutality. That is a very modest plea, vindicated by the European Convention on Human Rights.

    Similarly, USA is considered a democratic nation where “Rule of Law” prevails. The deported Indians certainly needed a better dignified humanly treatment.