Aahan: World-Class TB Delivery in Rural Bihar
Tuberculosis in Bihar
Bihar is one of the poorest states in India with an estimated 103 million people, most of them in villages, and more than 55 million below the poverty line. Encouragingly, a progressive government has been undertaking reforms to promote development.
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.
Progress (July '10-present)
- Catchment: Aahan serves a population of about 243,000 in the Dalsingh Sarai block in Bihar.
- Case-finding Communities have referred more than 7900 neighbors, relatives, and friends with probable TB to Aahan.
- Diagnosis: The program has overseen the diagnosis of 1996 patients suspected of TB.
- Treatment: Of patients who underwent diagnosis, 614 were diagnosed with TB, of which 412 were cured, and treatment continues for 143.
- Strengthening community health workers: Aahan's training and engagement has led to 134 government female health workers delivering drugs in their communities.
Interventions
- Strengthening ASHA workers
Female community health workers (ASHA) play a critical role in rural public health. Aahan goes beyond technical training, and takes a broader view of empowerment by being committed to realizing the full potential of every ASHA worker. E.g., Aahan is training 18 ASHA workers to run the entire program. These ASHA facilitators receive advanced training beyond what is required for routine drug delivery. In another initiative, around 30 ASHA participated in lessons to prepare them for entry into nursing colleges. A small literacy pilot was also launched. - Strengthening local staff
Aahan recruits all field staff from local communities. Staff are being groomed to run all operations independently. They receive mentoring, and are being trained in analyzing problems, formally posing and evaluating solutions, making effective presentations, interacting with stakeholders, etc. Staff now launch the program in all new catchment areas. - Mobilizing communities
Aahan believes that communities must take ultimate ownership of public health programs. The program engages extensively with a variety of stakeholders and institutions, including physicians, village government representatives, informal healthcare providers (for case referrals), schools, etc. - Research
Aahan carries out a variety of studies to measure and improve outcomes. For instance, in 2013 it conducted a large survey of the reliability of drug delivery. As a result of the study, the program instituted several changes which markedly improved reliability. Aahan now predicts and tracks patients considered likely to stop treatment, and takes pre-emptive measures to prevent dropouts.