From disease-specific to person-centred care

Tuberculosis (TB) rarely presents as a standalone disease in an individual. Many people with TB have other comorbidities or disease conditions that they must simultaneously cope with, while being on treatment for TB. Therefore, treating TB alone is not enough. Adopting integrated care approaches by transitioning from disease-specific to person-centred care can accelerate India’s efforts to achieve both universal health coverage and TB elimination. Simply put, we must treat the person and not the disease.

Take the example of Divya (name changed), a 48-year-old woman who was diagnosed with TB in 2023. She had been living with diabetes and hypertension for several years and it is highly likely that her diabetes played a role in her contracting TB. Crucially, she had poor glycemic control with a HbA1c over 10, which had a direct impact on her treatment for TB.

Infectious diseases like TB; non-communicable diseases such as diabetes and chronic respiratory diseases; malnutrition; and social and economic vulnerabilities inevitably intersect in individuals and families, adversely impacting outcomes and the overall quality of life. Recognising the interconnected nature of these multiple vulnerabilities is the first step towards delivering integrated care.

Treating TB and diabetes

As in the case of Divya, an important opportunity for integration is between TB and diabetes, given India’s growing diabetes burden. Over 15 years ago, the National TB Elimination Programme (NTEP) identified diabetes as a key comorbidity for TB, and rolled out formal bidirectional screening guidelines for TB-diabetes. Every person with TB must be screened for diabetes and people with diabetes must ideally be screened for TB once a year. Studies have shown that people with diabetes are more likely to develop active TB disease than those without; equally, people with TB who also have diabetes are more likely to have poor TB treatment outcomes.

In Chennai, in a cohort of over 9,000 people with TB for three years, the authors found that over one-third (34%) had diabetes, and of this group, 41% had poor glycemic control which is the biggest challenge. Monitoring the blood sugar levels of a person with TB and diabetes throughout the TB treatment period is therefore essential, as is expanding clinical management and the counselling that is provided from TB-specific guidance to also focus on overall lifestyle, physical activity, diet and nutrition etc.

Integrating respiratory care

Another important opportunity for integration is at the intersection of TB and Chronic Respiratory Diseases (CRD) such as asthma or Chronic Obstructive Pulmonary Disease (COPD), at the screening stage itself. Only a fraction of people with respiratory symptoms are eventually diagnosed with TB — the rest are likely to have viral flu, bronchitis, asthma etc. In REACH’s ongoing TB-CRD integrated care pilot in two districts each of Bihar and Tamil Nadu, nearly 3,000 people with COPD and asthma were identified and linked to care, among the 26,000 people who were screened for TB but found TB-negative. In addition, integrated care can also change the course of post-treatment follow-up, given that many people who complete TB treatment continue to have respiratory impairments.

Other areas of intersection include undernutrition and risk factors such as smoking and alcohol use. This multi-disease approach is already envisaged in the framework of the Ayushman Arogya Mandirs for delivering comprehensive care at the community and primary care levels.

Delivering integrated care at scale can have its share of challenges. At the health system level, it is a likely stressor on already strained human resources, with the brunt of the workload falling on community health workers. In addition, many of India’s large health programmes are vertical and not always designed to talk to each other, in terms of both human resources and data; this will require both creative and pragmatic solutions. Integrated care delivery will require adequate and additional human resources, a careful readjustment of the health worker to care recipient ratio and investment in periodic training.

Holistic wellness

Given that the NTEP is among India’s more robust, well-structured public health programmes, using TB as an entry point to identify and address closely associated morbidities such as diabetes, CRDs, undernutrition etc. will help optimise healthcare delivery and improve public health efficiency. More importantly, it could reduce delays in diagnosis, minimise the need for visits to several health facilities, and help overcome barriers to accessing a continuum of care.

With empathetic person-centred design, integrated healthcare delivery can be a win-win for health systems, individuals and families affected by TB.

Anupama Srinivasan is Deputy Director of REACH. Dr. Ramya Ananthakrishnan is Director of REACH.