Direct benefit transfers may not be the best way to ensure that tuberculosis patients get essential nutrition, say public health activists, who are critical of such a provision in the budget.
Finance Minister Arun Jaitley announced in his budget speech that the government would allocate Rs 600 crore for the coming financial year for nutritional support of tuberculosis patients. This, he said, will ensure that all tuberculosis patients in India get Rs 500 every month for their nutritional needs for the duration of their treatment.
The announcement is in line with the Revised National Tuberculosis Control Programme’s National Strategic plan for up to 2022, which states that the programme will provide a monthly support of Rs 500 via direct benefit transfer to all patients “to incentivise treatment completion”. However, a guidance document on nutritional care and support of tuberculosis patients in India drawn up last year by the Central TB Division, the Ministry of Health and Family Welfare with support from the World Health Organisation recommends distributing protein-rich food baskets as nutritional support. The document provides operational guidelines to implement such a scheme and does not mentions direct benefit transfer.
“Direct benefit transfer is a political decision and may not really help patients,” said Dr Yogesh Jain, a paediatrician in Chhattisgarh and founding member of the public health non-government organisation Jan Swasthya Sahyog. “It is for the optics, if they are serious, they should provide actual food.”
Jain argues that Rs 500 a month is too little for adequate nutrition for a person recovering from tuberculosis, given that the disease is closely linked with poverty in India. “The problem is that the food ration being given to a TB patient will be shared by the family so it will get diluted,” he said. “Hence, it is better to give them a food basket with adequate items to meet the nutritional support [of the family].”
Jain has been instrumental in framing the Chhattisgarh government’s nutrition programme for tuberculosis patients, in which the state distributes food baskets to patients for eight months. The programme, which was launched last year, costs the Chhattisgarh government about Rs 800 per person.
In contrast, under the Centre’s proposal of cash transfers of Rs 500 per patient, given the highly fluctuating costs of food grains, pulses and eggs, there is no guarantee that a patient will get their required amount of protein. According to Jain, a direct benefit transfer might ensure that a tuberculosis patient buys three eggs and nothing else. “But that is not enough to even meet the protein requirement,” he said. “A healthy person requires 50 to 60 grams of protein every day. And what about calories? It would have been better if the government provided for food baskets which ensures that the patient gets the right quantity of food items which can help increase the protein intake.”
The group of doctors and dieticians who drafted the guidance document recommended that TB patients should be given food baskets, their ration from the public distribution system be enhanced and they should be provided with daily multivitamin supplements.
Some officials at the Ministry of Health and Family Welfare insisted that cash transfers were more practical than providing food. “The health ministry is responsible for providing diagnosis and treatment,” said Sunil Khaparde, deputy director general for tuberculosis. “We cannot start providing rations to patients as it requires a different infrastructure, which the health ministry does not have.”
The argument stands at odds with the Modi government’s claims of inter-ministerial collaboration.
At the same time, Manoj Jhalani, additional secretary at the health ministry, said that the Centre would let state governments decide how to provide nutrition support. “It can be either cash transfer or kind,” he said.
The nutritional support under the Chhattisgarh programme is tailored to patients with drug sensitive tuberculosis for whom the treatment lasts between six and eight months. However, a drug resistant TB patient has a longer treatment schedule lasting at least 24 months. Chhattisgarh government has said it will extend the nutrition support to such patients over longer durations as long as the budget is adequate. “We have the budget to provide nutritional support for this fiscal year,” said Dr Madhav Rao Deshpande, the state officer for the TB control programme. “We want to provide the food packets to all patients throughout the treatment, depending on the budgetary provisions.”
Mumbai’s municipal corporation is also planning to kick off a programme to provide nutritional support to tuberculosis patients. “We will be providing a nine kilo food packet to TB patients [every month] which will consist of grains and pulses,” said Dr Daksha Shah, Mumbai’s TB officer. Dr Shah said that the contents of the food basket have been fixed in a way that the patient gets at least 30 grams of protein every day. Shah said that the corporation did not consider giving cash aid because it may be misused. “We really can’t tell what the patient will buy from the money we give them,” she said.
The Municipal Corporation of Greater Mumbai has earmarked Rs 13.50 crore in the budget this year to pay for the nutritional scheme that is expected to benefit close to 25,000 TB patients.
Jain said that the past experiences within India and abroad have shown that distributing aid in kind is beneficial for TB patients. “Even Haiti and Vietnam have provided food for TB patients and it has helped,” he said.
Tuberculosis and undernutrition are part of a vicious cycle. Undernutrition impairs immunity and predisposes to development of tuberculosis. Tuberculosis in turn leads to significant undernutrition which in turn worsens severity of tuberculosis, and increases the risks of a number of serious outcomes including death.
“Given the severe undernutrition in TB patients, nutritional support is an essential part of TB care,” said Dr Anurag Bhargava, professor of medicine, Yenepoya Medical College in Mangalore.
According to the results of a large study which Bhargava coordinated in rural India, the average weights of men and women were only 42 kg and 34 kg respectively, while according to Indian Council of Medical Research, the weight of a healthy Indian man or woman should be 60 kg and 55 kg respectively.
Further studies have shown that weight gains in Indian patients are poor because of an inability to afford a diet adequate in calories and proteins. This means that even at the end of treatment, patients are most often underweight and are between three and four times higher risk of recurrence of disease. Even in patients with serious forms of drug resistant tuberculosis, survival is linked to body weight and is three times higher in those above 50 kg.
According to Bhargava, a tuberculosis patient who weighs more than 50 kg is three times more likely to survive compared to a patient who weighs less than 50 kg.
Moreover, undernutrition in adults is the major driver of the epidemic in India, and 55% (or more than a million) of new cases were attributable to its effects, according to a 2014 study by Bhargava and others.
“We, as a country, need to closely look at addressing the problem of undernutrition which is responsible for spreading TB and hinders the treatment outcomes,” said Bhargava.