Increasing the direct benefit transfer to Rs.1,000 monthly, providing Rs.3,000 upon diagnosis, and offering nutritional assistance to individuals with tuberculosis could yield significant outcomes.
In India, tuberculosis (TB) continues to pose a significant public health challenge, leading to an estimated three million new cases and 300,000 TB-related deaths annually. The recent announcement by the Ministry of Health and Family Welfare to increase the direct benefit transfer under the Nikshay Poshan Yojana (NPY) from ₹500 to ₹1,000 per month throughout the treatment period, along with an upfront payment of ₹3,000 at diagnosis, marks a positive development. Furthermore, plans are underway to supply energy-rich nutritional supplements to malnourished patients for two months and extend nutritional and social assistance to their families. India stands out as one of the few high TB burden nations implementing such an extensive program to address patients’ nutritional requirements and financial hardships.
TB remains a disease influenced by social factors in both its causes and consequences. Conditions linked to poverty, such as overcrowding and malnutrition, heighten the vulnerability to TB. Additionally, prevalent risk factors like diabetes, smoking, and alcoholism are either more common or inadequately addressed among individuals living in poverty. Malnutrition alone contributes significantly, accounting for over a third to nearly half of new TB cases in India. The impoverished face a vicious cycle of limited access to primary healthcare, substandard quality of care, and poor treatment adherence, culminating in severe illness and heightened mortality risks. Their situation is dire, marked by loss of income, substantial disease-related costs, food insecurity, and often an inability to resume regular work due to the aftermath of the illness.
The Nikshay Poshan Yojana holds significant importance due to the prevalent severe undernutrition among TB patients in India, with average weights at diagnosis standing at 43 kg for adult men and 38 kg for adult women. Lack of nutritional assistance leads to poorer treatment outcomes and elevates the risk of death, as these patients struggle to gain weight early on, potentially facing persisting undernutrition even post-treatment and increasing the chances of recurring TB. Research indicates a substantial food insecurity prevalence in households affected by TB, underscoring the vital role of nutritional aid from a clinical, public health, and ethical perspective. This initiative is in line with India’s 2017 adoption of WHO guidelines for nutritional care in TB patients. Evidence strongly supports the effectiveness of providing food baskets as a form of nutritional support, shown to enhance treatment compliance, promote weight gain, facilitate a smooth return to work, and reduce mortality rates. The RATIONS trial demonstrated that patients receiving a monthly 10 kg food basket experienced more than a 50% decrease in mortality risk due to early weight gain. Additionally, a cost-effective intervention of a six-month supply of cereals and pulses, along with micronutrient supplements for family members, led to a significant reduction in new TB cases by up to 50%, equivalent to the impact of a vaccine.
The assessment conducted by the National Institute of Epidemiology (NIE) in Chennai on the NPY program spanning five years yields valuable insights. One key obstacle identified is the strain felt by TB program personnel as they juggle new projects, particularly due to the cumbersome nature of direct benefit transfer facilitation. Moreover, disadvantaged communities face hurdles in availing the benefits due to challenges such as inadequate documentation of identity, residency, banking facilities, and geographical distances. The evaluation from NIE reveals a concerning trend: individuals not receiving NPY benefits are at a significantly heightened risk of negative consequences, reflecting a four-fold increase in adverse outcomes.
As professionals in the healthcare and research sectors involved in this domain, certain clarifications and challenges in execution need attention. Firstly, there is a requirement for designated human resources for NPY tasks, which could also extend to newer ventures such as assessing household contacts. Secondly, tailored counseling materials for patients and their families are essential to underscore the significance of nutrition in the treatment regimen. These materials should feature locally accessible and culturally appropriate food options to enhance energy and calorie intake. The inadequacy of quality protein in impoverished households is a concern. Pulses, soybeans, groundnuts, milk, and eggs present more economical alternatives to supplements derived from them, warranting specific focus during counseling sessions. Thirdly, in light of the evidence advocating for food packages, the advisability of energy-dense supplements requires careful consideration. Commercial nutritional supplements pose risks of elevated expenses, confusion, reduced acceptability, and limited long-term viability. Given the high prevalence of severe malnutrition among our patients, a two-month period of nutritional assistance may prove insufficient.
Regarding Nikshay Mitra, there is an insufficiency in covering the most vulnerable individuals, necessitating a redesign. Given the substantial stigma surrounding tuberculosis, it is essential to have a clear directive discouraging the publication of images showing patients and their families receiving food aid. Furthermore, the effectiveness of nutritional, financial, and social support programs is heightened when they are seamlessly integrated with other healthcare components. Ensuring a consistent drug supply, improved management of concurrent health conditions, thorough assessment of high-risk indicators at diagnosis, and facilitating hospital admissions similar to the practices in Tamil Nadu are crucial for achieving improved treatment results.
