Improving Adherence: Long-term Tuberculosis Treatment Among Migrant Workers in India
This is a policy thought piece I wrote for my Behavioral Economics in Public Policy class this semester. I’m looking forward to any feedback on this essay as a part of my learning process!
Tuberculosis (TB) has been a chronic public health concern in India for several years. India has a high number of cases every year with 23% of new incident cases and 21% deaths caused by Tuberculosis (Singh, Kumar, 2019). This bacterial disease spread through airborne droplets or particles, is the leading infectious cause of death and took 1.8 million lives globally. (Pai, Bhamuk, Bhuyan, 2017). Furthermore, India also faces the challenge of combating drug-resistant TB that is caused due to mismanagement of drugs, prescriptions of low quality drugs as well as incomplete drug treatments regimes because of low adherence (CDC, 2017) As a result, TB eradication has become more cost and resource intensive endeavour.
The first policy response to tuberculosis at a national scale was the National Tuberculosis Control Programme (NTCP) launched in 1962. This programme aimed at detecting as many cases of TB as possible, provided effective treatment to counter the disease and its effects on health, invested in established tuberculosis centres at a district-level and involved an education and awareness training component. By 1998, this program had covered only 2% of the population (Singh, Kumar, 2019). In 2018, with an ambitious roadmap to eradicate Tuberculosis by 2025, the Government of India has announced the National Strategic Plan (NSP) with an estimated implementation cost of US$2.5 million.
This Strategic Plan outlines a four-point approach to combating the systemic challenges of Tuberculosis : Detect — Treat — Prevent — Build. The program includes ICT-based contact tracing and notification systems using technological tools, and monetary incentives for private TB Care providers to report new cases of TB and ensures free drugs and diagnostic tests for patients who seek testing in the private sector. While the program offers a financial incentive of INR 500 (USD 7) for nutritional support, there are no direct rewards/incentives to patients for successfully completing the treatment. Poverty and poverty-induced undernutrition being crucial social determinants of TB (RNTCP, 2018), good nutrition along with the treatment is important in combating TB in lower income groups.
The poor are twice more likely to have TB and three times less likely to have access to TB care and treatment and four times less likely to complete treatment (Kamineni, Wilson, et al, 2012). With private medical care facilities being a part of the ecosystem, the financially better off are able to seek advanced care in the private hospital ecosystem and despite subsidised treatment under the NSP, several low income groups especially those below the poverty line are still adversely affected due to no access to treatment facilities. The Planning Commission of India defines below poverty line as earning INR 32 per day (0.53 USD) in urban areas and INR 26 in rural areas (0.43 USD). While all citizens below the poverty line are adversely affected, the challenge of adherence to drug treatment is the most difficult for migrant workers who earn daily wages and are constantly moving from one part of the country, according to the NSP 2020 Plan (NSP, 2020).
‘Drug adherence is a classic problem of behavior and one of the key root causes of that has resulted in drug-resistant TB that becomes costlier and harder to treat over time’ (Ideas42, 2013). For a migrant worker, on a daily basis, choosing to visit a DOTS (directed observed treatment short-course) center over an hour of wage work is a challenging trade-off. DOTS centres implemented under the RNTCP is a strategy to improve adherence among patients. While DOTS has been a successful policy intervention in curbing the incident cases of TB, DOTS is ‘ineffective for lower-income patients, whose daily wages may depend on showing up to work and missing visits to the DOTS centre to take the medication’ (Ideas42, 2013). Poverty-induced lack of access, making tough trade-offs coupled with failure to adhere to long-term drug treatment puts this population at a high risk and a lesser chance to cure TB.
Redesigning Pill Leaflets:
The National Strategic Programme offers incentives to private organisations for successfully administering treatment to TB patients. This incentive can be extended to drug and pharmaceutical companies to create a packaging design that arranges multiple drugs that are to be consumed in the long-term treatment course. The time-discounting tendency and present bias often causes patients to postpone treatment and eventually abandon it. Also, the
‘over-reliance on faulty heuristics (abandoning treatment before course completion based on the disappearance of visible symptoms)’ (Ideas42, 2013). Being unable to tangibly see how far into the course of treatment they are can tackle this faulty heuristic. Each type of TB case requires a unique treatment. This pill leaflet is proposed to be designed for new cases of TB as follows: The treatment in intensive phase (IP) consists of eight weeks of Isoniazid (INH), Rifampicin, Pyrazinamide and Ethambutol (HRZE) in daily doses as per four weight band categories and in continuation phase, three drug FDCs- Rifampicin, Isoniazid, and Ethambutol (HRE) are continued for 16 weeks’ (NSP, 2020). The redesign involves curating all the individual drugs into a single leaflet specifically designed for self-administration by the patient and to reduce dependency and frequency of visits to DOTS centers (not eliminate them), so that a missed visit does not have to mean missing drug treatment for a day, keeping in mind the migrant worker population.
Physically visualizing their progress in the treatment using the pill leaflet in itself serves as a visualization of information and offers a low-cost substitute for digital tracking. Studies have shown that switching from paper-based to electronic tracking can improve adherence to treatment (Bossuroy, Delavallade, Pons, 2020), but the inclusion of low-income migrant workers in digital tracking may cause exclusion errors. Each pill leaflet could be linked to the patient’s Aadhar card, to ensure tracking and adherence, without putting the load of tracking on the patient itself. Each pill leaflet can also be affiliated to specific DOTS centers.
Furthermore, the information overload of not only taking the pills over a long course of time but also remembering a chronology and order of taking the pill may cause information overload and result in non-adherence. This behavioral intervention is a mechanism to strengthen the current offerings of the four pillar strategies of the NSP rather than replace it. In addition to the Pill leaflets, the nutrition incentive of INR 500 that is currently enlisted in the NSP, can be split into smaller amounts and paid to the migrant worker in return for the empty pill leaflet, to then receive the next share of the incentive amount.
The mechanism of splitting the incentive into small parts is a substitute to ensure that there is at least some amount of observation involved since this intervention is meant for self-administration. This would help in course correction to ensure adherence early on if required. In this way, the policy intervention nudges migrant workers to collect their nutrition
incentive in return for a complete pill leaflet without altering economic incentives. While splitting incentives into smaller portions may not seem as valuable as receiving the entire amount upfront, ensuring that the amount of each portion is higher than their daily earnings is important. Alternately, in the design of the pilot RCT, testing the value of the current nutritional incentive and using the acquired data to set more handsome incentives in the future, will be one goal of launching the pilot study. In order to successfully create these new pill leaflets, a public-private partnership with drug companies under the NSP budget, can be laid out. Because TB treatment includes more than one type of drug, the partnership will be important to regular private companies to ensure the quality and fair price of the drugs. Not only is it important for the TB drugs to be of good quality, but good packaging that provides an effective affordance to help take small but certain steps towards long-term treatment is key in implementing this behavioral policy.
Factors that result in incomplete treatment include lack of patient counselling and education around the importance of adherence. While free medication that is given to the poor under the NSP is important, there is a lack of effective coaching and conversation around the importance of continued treatment and taking pills for long durations to ensure that the medication is effective, and does not result in drug-resistance TB. In addition to the Pill Leaflet redesign, frontline health workers that are also known as accredited social health activists (ASHAs) who operate at the village and district level can be provided with discussion guides that include:
- Stories of patients who overcame TB through long-term treatment.
- For migrant workers, whose livelihood depends on their daily wage, framing the loss they would avoid by adhering to treatment, can be effective in continued treatment.
Designing a Randomised Control Trial (RCT) Study:
Since a DOTS center is a district-level unit, a Randomised Control Trial (RCT) can be conducted in one-two districts of a State that is performing low in TB outcomes. Both districts must be in the same state but not in proximity to each other to avoid spillover effects. The choice of the State would be based on the population of migrant workers. For example, urban areas like the greater Delhi area see a lot of incoming migrant workers. While the existing framework of programs under the National Strategic Plan is operational, the RCT pilot will involve sending these new pill leaflets for specific categories of TB cases to specific DOTS centers in the district. Manufacturing these leaflets will be a cost incurred towards this intervention. Additionally, a time cost will be incurred because of the training that Frontline ASHAs and DOTS center liaisons will have to take for this pilot study. If this RCT is successful, rolling it out in phases to geographies where there are high migrant populations will be important for external validity. This intervention, while designed keeping in mind migrant workers, can be tested with other low-income groups, to ensure external validity as well. For example, treatment for new cases of drug-sensitive TB is different from drug-resistant cases. For this pilot study, the pill leaflets will be designed only for new drug-sensitive cases of TB. Treatment subjects would be patients who are first-time visitors to DOTS centers, who fall under the category of daily wage workers.
Potential Challenges and Opposition:
An intervention that includes a redesign of existing pharmaceutical packaging could face pushback from Pharma companies to reinvent their packaging designs and processes. On the other hand, if the pill leaflet design for self-administration does not achieve the expected results, the DOTS center can continue utilizing the pill leaflets for traditional observed treatment at the center. One of the unintended consequences of promoting self-administration (as opposed to observed treatment) intervention may give rise to malpractices of patients selling medicines outside of the DOTS and NSP ecosystem for economic gain. This will be a crucial consideration before scaling the RCT to a larger scale. Misinformation about physical health and misconception about modes of transmission of TB is rampant and tangled in social norms around TB treatment. Taboos related to TB are associated with specific demographics that may hinder acceptance of the medicine, as it does currently. For example, due to HIV and TB being comorbidities, belief systems create a sense of taboo around the disease(Mathew & Takalkar, 2007). TB medication is also assumed to cause a lack of fertility that may cause abrasive conditions especially for female patients in India(Mathew & Takalkar, 2007).
Public Health in India has often not enjoyed a significant share of the nation’s GDP. It is important that the Government channels more funds towards programs that ensure better outcomes for a healthy future for all sections of society, especially for a disease such as Tuberculosis that is curable. Our long fight against TB is a matter of national pride and interventions that make the Tuberculosis Program robust are likely to get non-partisan support. Even though it seems like an elephantine task to overcome the diseases and achieve perfect health outcomes, it has been an initiative that has been at the center of attention in India. If the National Tuberculosis program’s new Strategic Plan to eradicate Tuberculosis from India by 2025 is successful, and as a result, ensures that at-risk demographic groups have had access to the required coverage under it, it will be deemed as a good successful policy because it made someone better off, without making anyone else worse-off.
References:
Singh, S., Kumar S., Tuberculosis in India: Road to Elimination (2019, Jan 12).
Department of Community Medicine, Dr. Babasaheb Ambedkar Medical College and Hospital, New Delhi, India https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6592106/?report=printable
Pai, M., Bhaumik, S., & Bhuyan, S. S. (2017). India’s plan to eliminate tuberculosis by 2025: converting rhetoric into reality. BMJ global health, 2(2), e000326. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5435272/
Bossuroy T., Delavallade C. , Pons V. (2020). On Track: Healthcare, Patient Data, and
Provider Performance. J-PAL Policy Briefcase. https://www.povertyactionlab.org/blog/6-25-20/connecting-dots-detection-cure
(Kamineni, Wilson, et al, 2012)
Kamineni, V. V., Wilson, N., Das, A., Satyanarayana, S., Chadha, S., Sachdeva, K. S., & Chauhan, L. S. (2012). Addressing poverty through disease control programmes: examples from Tuberculosis control in India. International journal for equity in health, 11, 17. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3324374/#B9
Ideas 42 (2013). Increasing Adherence to TB Medication. Clinton Global Initiative.
NSP, (2020). National Strategic Plan to End Tuberculosis in India. Ministry of Health with Family Welfare, Government of India. https://drive.google.com/file/d/1TLGk-6PBrPyLqBhe9lN4lWnsNLMBLVra/view
Mathew, A. S., & Takalkar, A. M. (2007). Living with Tuberculosis: The Myths and the Stigma from the Indian Perspective. Clinical Infectious Diseases, 45(9), 1247–1247. https://doi.org/10.1086/522312
