TB in particular affects a large number of India’s poor due to social, economic and environmental factors. Of these, poverty and undernutrition are well-established risk factors for TB in India. Evidence has shown that both these factors are directly linked to completing TB treatment and its recovery. People with TB frequently experience severe economic barriers to health care, including high expenses related to diagnosis and treatment, as well as indirect costs due to loss of income. This is particularly true of those who work in the informal sector. Poor nutrition is inextricably linked to poverty and hunger. It delays recovery and also causes higher mortality among TB affected.

HOW THE ECONOMICS OF TB KILLS

• For the poor, the economic burden of TB creates barriers to prompt diagnosis, which may then lead to continuing transmission.

• When diagnosed, expenses such as transportation and the cost of food, combined with the loss of income, push families into debt and are disincentives to continuing treatment.

• In India a study established that an individual diagnosed with TB in India lost an average of 3 months’ worth of wages.

• Delayed, interrupted and incomplete treatment due to poverty not only poses a serious risk to individual health, but also increases the disease risk to others in the household and beyond.

• Poor nutrition among TB infected leads to wasting, poor recovery and often unsuccessful treatment outcomes.

• For poor households, the costs of TB lead to reduced consumption, sale of assets, and greater debt, all of which result in further impoverishment, and often, destitution.

WHAT CAN BE DONE?

Based on the available evidence and global experiences, India’s Tuberculosis Control Programme can create the following programmes to support TB patients in need:

EXPANSION OF ECONOMIC ASSISTANCE PROGRAMMES

India has launched numerous direct transfers of money programs but many of these remain inaccessible due to lack of information, ineffective execution and systemic problems. These consist of cash paid as part of a social security system or a programme incentive, transport reimbursements, treatment allowances, and the like that are paid directly to affected individuals to ensure they do not become desperately poor or fall into debt. In most cases, these amounts remain nominal and need to be increased as well.

FOOD AND NUTRITION ASSISTANCE 

All individuals with active TB should receive a periodic assessment of their nutritional status and appropriate counselling based on their nutritional status, starting at diagnosis and continuing throughout the treatment. If unable to afford appropriate nutrition, they should be provided with locally available nutrient-rich or fortified supplementary foods, to restore normal nutritional status. Food assistance improves access and adherence to treatment and mitigates the financial and social consequences of TB. While some of these exist in some states these need to be expanded nationwide and the amounts under them need to be increased.

TRAVEL SUPPORT

Travel vouchers or support can be a great enabler for continuing treatment for poor individuals, households or families. This is especially true for areas where treatment centres are far apart and accessing them is expensive.

COMMUNITY BASED SYSTEMS OF CARE

Clinic-based treatment supervision poses a significant economic burden on patients. Also, poor geographical and financial access to health services often prevent or delay health seeking among people with TB. The creation or strengthening of community-based treatment supervision programmes would have the greatest potential impact on reducing patients' TB-related costs. Also expansion of adherence technologies such as 99 DOTS can create more empowered systems of care where patients are allowed independence to managing their treatment.

SKILL DEVELOPMENT AND FINANCIAL ASSISTANCE

Training programmes or credits that help individuals or families affected by TB to generate income after treatment are very important. This is particularly relevant for those TB affected that work in the informal sector and lose employment due to TB. This ensures that families and individuals are able to rebuild their lives and do not fall into poverty due to TB.

All these recommendations have been derived from our respective experiences. We urge the government to take action on the aforementioned issues and in turn ensure effective TB prevention and control in India.