February 19, 2016 | ,

A new approach to battling TB in Mumbai’s crowded slums

Innovative program uses database, call center, and outreach workers armed with vouchers to connect a fragmented care system.
Indian family portrait in small cramped room.
“For a long time I used to be confined to lying down because of the pain I had to endure,” said laborer Mohammad Azam, a TB patient in Mumbai’s crowded Dharavi slum. Azam, his mother Malikunnissa, wife Rabiya Banu, and their children live in this small windowless space. Photo: PATH/Tom Furtwangler.

In the teeming slums of Mumbai, India, a laborer like Mohammad Azam might ignore a persistent cough or strange spinal pain as long as he could, working daily as the sole breadwinner for his family. But finally, unable to sleep, he might skip a day of labor and reluctantly spend the fee to consult with an informal medical provider.

India has more cases of tuberculosis (TB) than any other country—an estimated 2.3 million. And in densely populated slums like Dharavi, in Mumbai, multidrug-resistant TB rates are alarmingly high. These statistics are driven in part by crowded living conditions, but also partly because, until now, local care providers lacked the support, incentives, and referral networks to accurately diagnose and get enough TB patients into treatment. And those patients who did get into treatment did not always receive adequate support to complete the full course of drugs, a process that can take as long as nine months.

Man with stethoscope standing in doorway
At Dr. Imran Sheikh’s two-room consulting office, patients crowded outside his door, waiting impatiently as he spared a few minutes for questions about this voucher program. Photo: PATH/Tom Furtwangler.

Visiting a busy local two-room private clinic like Dr. Imran Sheikh’s, it’s easy to imagine how tuberculosis might get misdiagnosed—or patients lost to follow-up—in the swirl of humanity for which Mumbai is legendary. And that’s what makes these local first-line medical providers a key focus of PATH’s innovative urban TB provider networking project: the Private Provider Interface Agency (PPIA).

Dr. Sheikh, who could only spare a few minutes as patients crowded his waiting area, told us he refers as many as 15 potential TB patients per month for x-rays. “When I am unsure, I suggest the diagnostics and give a voucher. With the results coming in quickly and the patients being tracked by the PPIA, I am immediately able to refer the patient to a chest physician,” he explains.

Ajit Bhatt overlooking the crowded buildings of Dharavi slum.
PPIA field officer Ajit Bhatt left a career in medical sales to work creating referral networks in this innovative urban TB program. “I used to travel 20 days a month,” he says. Dharavi slum, shown behind him, is his new territory in a job that gives him enormous satisfaction—and lets him go home every night. Photo: PATH/Tom Furtwangler.

Following PPIA field officer Ajit G Bhatt through the narrow passages of Dharavi from provider to provider, each serving a small, densely crowded neighborhood, it becomes easier to understand the innovative way this new care-and-referral network is linking previously disconnected systems.

Local first-line private providers are linked by field officers like Bhatt to nearby x-ray and sputum-testing facilities through vouchers which the providers can give to patients for free or subsidized TB diagnostics at those facilities. Any doubt that a local doctor may have about a patient’s nagging cough is put to rest with state-of-the-art diagnostics, and patients confirmed to have TB are referred to experienced chest physicians, who are better able to manage their TB treatment. The medicines they receive are subsidized, again paid through vouchers generated by the centralized system and transferred over mobile phones.

Afreen Shiekh talking on a smartphone and writing in a ledger.
Community field worker Afreen Shiekh speaks to the Delhi call center to generate a drug voucher for a patient at the Sai Hospital in the heart of Dharavi slum in Mumbai. Photo: PATH/Tom Furtwangler.

These registrations also help India enlist patients into its Universal Access to TB Care (UATBC) national program. The call center of the UATBC in Delhi is a busy place. While local case workers are the first line of support for TB patients in the Mumbai PPIA program, the UATBC also provides counseling on the phone.

Trained phone counselors remind patients to collect their next lot of medicines, and also hand-hold some patients who need support during the long course of treatment.  Proactive call center outreach, inquiring about the patient’s progress, has helped many patients return to their medicine regimens when they have either forgotten or have begun to despair that they will not get better.

PATH’s PPIA project director Shibu Vijayan explains that all these efforts are being led by the Mumbai Mission for TB Control, which recognized the urgency of the situation and the need for an innovative intervention. PPIA has registered 17,489 TB cases as of December 2015. Says PATH’s PPIA marketing manager Ravdeep Kaur Gandhi, “The process of consultation with the doctors, hospitals, and laboratories is very transparent. The private doctors are allowed to choose which chest physician they would like to refer their patient to for confirmed diagnosis and treatment initiation.”

It’s a whole new procedure, piloted for the first time at this scale in Mumbai, and PATH staff in the PPIA project are constantly ironing out issues in the community, helping doctors understand the technicalities of the voucher system, and juggling dynamics of a very complex program. Ajit Bhatt recalls doctors calling him at all hours to seek his help in getting the voucher system in place, grateful for his steady guidance. “There is a lot of respect for my work here. And I feel very proud when people say the work of the Mumbai Mission for TB Control is very good!”

Indian woman looks on in dark room
Mohammad Azam’s mother Malikunnissa listens attentively as her son describes his painful TB symptoms. Photo: PATH/Tom Furtwangler.

Back in the tiny, windowless, ten-by-ten brick room with Mohammad Azam’s family, his mother chimes in, vocal in her enthusiasm for the impact this program has had on her son. She remembers how debilitating spine pain kept Azam nearly bedridden. Exiting the crowded space and returning through narrow passageways to the slightly less crowded street, Azam’s PATH-supported counselor Vishal Giri, of the community organization Maharashtra Jan Vikas, takes a moment to sit down with him on a stoop. “You’re doing ok?” he asks in Hindi with genuine concern.

Within this massive and complex urban health project, powered by sophisticated databases, smartphones, vouchers, and a call center, these moments of personal connection are still one of the keys to its remarkable success.

Two men sitting on a stoop and talking.
For many patients, the personal connection with a trained and supportive community worker helps them complete what is still known to be a very difficult treatment regimen. Here, field worker Vishal Giri checks in with Azam. Photo: PATH/Tom Furtwangler.
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  • Sushmita Malaviya is a communications officer for PATH’s Vaccine Development Program, based in Delhi, India.
  • Tom Furtwangler is a senior communications officer at PATH.