Communities

Aahan: World-Class TB Delivery Through Research

Tuberculosis in Bihar

Bihar is one of the poorest states in India with an estimated 103 million people, most of them in villages. The per capita income, at purchasing parity, is about $348. Encouragingly, a progressive government has arrested the precipitous decline, and was recently re-elected.

Bihar has about 180,000 new cases of TB every year, and there are hurdles throughout the delivery chain. Case-finding is hard since patients prefer private providers who are not integrated with the national TB program (NTP). Patients in private care typically stop taking drugs after a month or two because of poverty. Diagnosis is difficult since only 30-50% of patients test positive. The rest are diagnosed using questionable blood tests, or by using antibiotics to rule out other respiratory diseases. Finally, ensuring adherence over 6-8 months is challenging. For instance, asymptomatic and often undernourished patients may have little incentive to take drugs that cause gastrointestinal side-effects. Others might migrate to cities for work.

The consequence is that only half the case load is managed by the NTP. Patients seeking private care run up large debts, report extremely poor adherence, and are at high risk for mortality and drug resistance.

The Aahan TB Program

Aahan is a program of Innovators In Health, the Prajnopaya Foundation and the Swasti Seva Samiti that provides world-class care to rural TB patients using means that can be replicated and scaled. Aahan's focus is changing outcomes by building the community's capacity and then transferring ownership to the community, rather than establishing a parallel delivery network. The program works closely with the NTP and the Bihar government to ensure funding and management capacity to scale field-tested protocols state-wide.

Progress (July '10-present)

  • Catchment: Aahan's staff of 12 serves 33 villages in the Dalsingh Sarai block in Bihar, with a combined population of about 60,000.
  • Case-finding and diagnosis: More than 650 patients suspected of TB have undergone diagnosis. All patients were referred by community members.
  • Treatment: 158 patients have been diagnosed with TB, of which 70 have been cured, and treatment continues for the rest.
  • Training: Six physicians have attended two workshops on diagnosis and treatment. Awareness sessions conducted for over 60 ASHA workers (female community health workers (CHWs)), 30 community representatives, and 50 "village doctors" (unlicensed practitioners). Training was conducted with the NTP and state health officials.
  • Surveys: More than 1200 residents surveyed to establish health seeking behavior and identify key stakeholders.

Interventions

  • Case-finding
    Detecting cases early is important to improve the patient's chances and reduce transmission. Aahan is experimenting with incentive-based networks of community health workers and "village doctors" to report symptomatic cases.
  • Diagnosis
    Since the primary test has a sensitivity of only 50%, Aahan is measuring the cost and performance of fluorescence microscopy and cultures in the rural context. It is also working with physicians to strengthen the differential diagnosis of respiratory illness.
  • Strengthening stakeholders
    Aahan conducts short surveys in target communities to discover the most important stakeholders in healthcare. These include qualified physicians, unlicensed practitioners, community health workers, private labs, etc. Aahan conducts training, offers market-rate incentives, and improves communication between stakeholders to improve the quality of TB delivery in both the private and public sector.
  • Reviving the village government
    Aahan is currently designing the revival of Village Health and Sanitation Committees, a representative body in the village government which will take ownership of the TB program.
  • Building the capacity of female community health workers (ASHA)
    With the help of the NTP and the state government, Aahan has revived drug delivery by ASHA workers. Aahan is now designing a literacy program and academic fellowships for promising CHWs.