Assessing the Role of Pradhan Mantri TB Mukt Bharat Abhiyaan in India’s Fight against TB: A National-level Data-based Research Investigation

Abstract

Background:

Tuberculosis (TB) remains a global health challenge, with India being severely affected. Despite efforts like the End TB Strategy and the National Strategic Plan for TB Control, the burden persists, necessitating innovative approaches such as the Pradhan Mantri TB Mukt Bharat Abhiyaan (PMTBMBA). This study aims to assess the implementation and reach of PMTBMBA nutritional support, examining factors that influence its uptake among persons with TB (PwTB) and Ni-kshay Mitra: a voluntary donor to PwTB.

Materials and Methods:

Aggregated data variables from the records and registers of Ni-kshay Portal were analyzed for the duration of September 2022 to May 2023. It examined the nutritional support coverage under PMTBMBA initiative and outcomes of PwTB and uptake of scheme among Ni-kshay Mitra.

Results:

The PMTBMBA showed 51% Ni-kshay Mitra supported, with varying levels of support provision across the states. Notably, 9.6% of PwTB documented with receipt of benefits during initial months, with better coverage in certain states. Most of the Ni-kshay Mitra distributed nutritional support, and analysis demonstrated a significant association between Ni-kshay Mitra support and improved treatment outcomes. This finding was confirmed through Chi-square analysis (P < 0.001, OR = 2.2) and regression analysis, showing that PwTB without support are significantly more likely to have unfavorable outcomes (Exp (B) =1.671).

Conclusion:

The PMTBMBA represents a crucial initiative in India’s TB control efforts, integrating comprehensive support for PwTB. However, challenges in volunteer engagement and geographical disparities highlight the need for targeted strategies and equitable nutritional support allocation. The study underscores the importance of community involvement and nutritional support in enhancing TB treatment outcomes, emphasizing the program’s potential to drive progress toward TB elimination.

INTRODUCTION

Tuberculosis (TB) remains a global public health challenge, leading to considerable toll on individuals and communities across the world. Despite substantial progress in reducing TB incidence over the past decades, the World Health Organization (WHO) reported an estimated global total of 10.6 million people fell ill and a total of 1.3 million died with TB in 2022. The net reduction in the TB incidence rate (19%) and reduction in total number of deaths (8.7%) from the year 2015 to 2022 was far from the milestone of the WHO End TB Strategy of 50% and 75% reduction by 2025, respectively.[1,2] India, in particular, struggles with high burden of TB. In 2021, India reported an alarming 2.1 million new TB cases, making it the world’s highest TB-burden country.[3] The persistent threat of TB highlights the pressing need for effective TB control and comprehensive PwTB support mechanisms.

The End TB strategy 2015 advocates for the implementation of robust policies, including social protection and poverty alleviation, as crucial components of the worldwide TB response.[4] The 2018 United Nations General Assembly High-Level Meeting on Tuberculosis (TB) expressed a commitment to intensify efforts and allocate more resources in order to expand coverage and achieve the objective of eliminating TB.[5,6] Recognizing the urgency of this issue, the National Strategic Plan (NSP) for TB Control 2017–2025 under National TB Elimination Program (NTEP) was introduced with four strategic pillars: Detect, Treat, Prevent, and Build.[7,8]

To support and express the political commitment toward global declarations and end strategy, an innovative approach to involve communities in PwTB support, “Pradhan Mantri TB Mukt Bharat Abhiyaan” (PMTBMBA), was launched in 2022 by the Hon’ble President of India.[9] The PMTBMBA initiative was designed as a critical initiative aimed at addressing the complex needs of persons with TB (PwTB), with a focus on the “Prevent” and “Build” pillars of NSP. A second high-level meeting was held in September 2023 reiterating the global commitment on strengthening the provision of comprehensive care for all people by using specific model of care for nutrition, social protection, and rehabilitation.[10]

Pradhan Mantri TB Mukt Bharat Abhiyaan

Launched in 2022, PMTBMBA initiative adopts a multipronged approach to combat TB by enrolling a Ni-kshay Mitra (donor) to support PwTB. It emphasizes comprehensive support encompassing nutritional support, additional nutritional supplements, diagnostic aid, and vocational support through voluntary contribution. In order to support government efforts in combating TB, Ni-kshay Mitra (Donor) including corporates, elected representatives, individuals, institutions, nongovernmental organizations, political parties, and partners provide support by adopting PwTB from health facilities, blocks, urban wards, districts, or states. This assistance is provided in accordance with district-specific requirements and in coordination with the district administration. The Ni-kshay Mitra provides the abovementioned nonmonetary support to on-treatment PwTB who have given consent for receiving the support, in the selected health facilities/blocks/urban wards/districts/states for a minimum duration of 6 months up to 3 years. In order to ensure that PwTB receives the benefits from the Ni-kshay Mitra, the community health workers are at the forefront and are responsible for engagement, coordination, and counseling of the beneficiaries in this regard.[9]

Undernutrition and tuberculosis

The provision of nutritional support has long been recognized as a critical component of TB care. Malnutrition frequently coexists with TB, posing a hindrance to recovery.[11,12] TB death rates in a community sometimes show an inverse relationship with the economic status of different groups. Individuals with active TB have a notably reduced nutritional status and higher prevalence of undernutrition compared to healthy individuals.[13,14] Hence, the distribution of nutritional kits under PMTBMBA initiative is of utmost importance for the PwTB. The nutritional support not only contributes to improved treatment outcomes Ni-kshay but also plays a pivotal role in preventing relapses and mortality among PwTB.[15,16] The scheme, along with the Nikshay Poshan Yojana (NPY), addresses the social protection[17] and nutritional aspect of care.

Despite the clear objectives of the PMTBMBA initiative, evaluating its initial implementation and reach remains essential. So far, in-depth research on PMTBMBA’s efficacy has been limited. The study was commissioned by India’s National Tuberculosis Elimination Program (NTEP) to provide guidance for evidence-based strategic planning. This study aims to analyze factors influencing uptake among PwTB and Ni-kshay Mitra, focusing on geographical variations across states and engagement levels among Ni-kshay Mitra, to support PwTB in their overall treatment outcome.

MATERIAL AND METHODS

Study design and settings

A descriptive cross-sectional and ecological study design was employed to examine country level performance on key parameters of PMTBMBA support coverage for the duration of September 2022 to May 2023. This design allowed for the analysis of aggregated record-based data over time, providing a holistic view of the uptake of the PMTBMBA at the country level and state level and among beneficiaries.

Process of providing support to the PwTB under PMTBMBA

In this initiative, the units, operating within health facilities, blocks, urban wards, and districts, are required to obtain consent from on treatment PwTB who wish to receive support as a continuous process round the year. Simultaneously, the NTEP teams were tasked with identifying Ni-kshay Mitra (donor) with willingness to adopt PwTB. The registration of Ni-kshay Mitra is undertaken with their agreement to support the PwTB for a particular period of time. The Ni-kshay Mitra can adopt one individual with TB or group of PwTB from the desired geography. Once the list of consented PwTB is finalized, the district team links the registered Ni-kshay Mitra to the individual with TB or group of PwTB. Ni-kshay Mitra then provides the support to the individual with TB directly or with the help of a health system on a particular day of the month for an agreed duration. The initiative follows two phases for the PwTB: consent and support receipt. The Ni-kshay Mitra follows three phases: registration, linkage, and support provision.

Study population and sample

The study population was all persons with TB and Ni-kshay Mitra recorded in the Ni-kshay Portal. The data extraction process was undertaken to assess the PwTB level and Ni-kshay Mitra-related variables.

Source of data, data variables, and extraction

Ni-kshay Mitra related data variables: From Ni-kshay Portal, aggregate reported data of PMTBMBA were extracted with variables, that is, names of state, Ni-kshay mitra ID, category of Ni-kshay Mitra, details of registration, linkage, and support delivered to PwTB. A total of 82,205 Ni-kshay Mitras were registered during the period from September 2022 to May 2023 in the Ni-kshay Portal. The compiled datasets of Ni-kshay Mitra who had provided support were triangulated with the eligible beneficiaries. The rate of conversion from registration to actual support provision suggests the coverage of Ni-kshay Mitra’s engagement under this initiative.

Persons with TB-related data variables: As of May 2023, the notification registers for 2021, 2022, and 2023 were examined as described in the methodology. From Ni-kshay Portal, aggregate data from notification registers were extracted with variables, that is, Ni-kshay ID of the PwTB, names of state, demographic details, program services, clinical profile, treatment regimen and outcome of treatment details, consent history, and received support from linked Ni-kshay Mitra. The following parameters were used for the cohort of PwTB notified in 2021, 2022, and January to May 2023 to analyze the 2,641,282 reported PwTB for the PMTBMBA benefits.

• Inclusion – All on-treatment PwTB whose treatment outcome was due between September 2022 and May 2023 depending on the treatment regimen.

• Exclusion – PwTB who were diagnosed, but not on-treatment, and reported with the duplicate IDs, wrongly diagnosed, and untraceable migrated and PwTB who refused for anti-TB treatment.

Impact on treatment outcome: The abovementioned eligible cohort was further screened using variables that followed to generate an important association between PMTBMBA support and its effect on treatment outcome.

• By including PwTB who were put on treatment in the month of September, October, and November 2022 and drug-sensitive PwTB and whose treatment outcome was decided before May 31, 2023.

• By excluding the individuals with TB whose treatment regimen changed and drug-resistant PwTB whose treatment usually lasts for 8 months to 2 years.

In the study, a rigorous validation process was applied to the secondary datasets, including duplicate removal, cross-checking within datasets, and verifying data consistency and completeness. Additional steps involved checking for missing values and outliers. The Ni-kshay data used had already undergone primary validation within the NTEP program, ensuring baseline data quality.

Data analysis and statistics

The data management and statistical analyses were conducted using a combination of Microsoft Excel (Redmond, WA, USA) and the R Studio software (version 4.4.0). In accordance with the objectives of the study, key parameters related to Ni-kshay Mitra and PwTB were identified for analysis, aligning with the process flow of the PMTBMBA. The state-specific variables, such as the count of Ni-kshay Mitra providing support, the categorization of Ni-kshay Mitra, and the count of eligible PwTB receiving support, were rigorously examined. PwTB-level variables were also subject to comprehensive analysis. To elucidate the relationship between PMTBMBA support variables and their initial impact on treatment outcomes, regression analysis was employed.

Ethics and consent

The ethical considerations and approval request were reviewed by Institutional Ethical Committee of Indian Institute of Public Health, Gandhinagar, and approved (TRC-IEC no. 02/2023-24). Confidentiality measures were implemented to safeguard the privacy of PwTB and Ni-kshay Mitra, with data anonymization techniques applied to protect sensitive information. Additionally, the study strictly adhered to ethical guidelines, including those outlined in the Declaration of Helsinki and other relevant national and international regulations. Throughout the research process, the wellbeing and rights of participants were of utmost importance, and ethical approval was sought from the appropriate regulatory bodies to conduct the study.

RESULTS

The PMTBMBA relies on key stakeholders, Ni-kshay Mitra, Health System, and persons with TB (PwTB) to drive its implementation and supportive course corrections to ensure the reach to the intended beneficiaries. The data analysis of the following parameters had provided an in-depth understanding of the actual support provided by the Ni-kshay Mitras, coverage among the states, coverage among PwTB, and impact of support on their treatment outcomes.

Uptake of PMTMBA among Ni-kshay Mitra

Registration to support provision

Out of 82,205 registered Ni-kshay Mitras, 77,145 (94%) were linked to PwTB, but only 39,015 (51%) provided support to PwTB. This indicates a lower conversion rate, with less than half of registered Ni-kshay Mitras engaging directly in support provision. This trend emerged from the initiation phase, with 63% registering within 4 months (September to December 2022). The study observed that out of 38,015, around 9% of Ni-kshay Mitra have registered and provided support from the different geographies of the states and country. As per Figure 1, corporates and health institutions were higher in portions of support provisions covering one or more districts and states in their service areas.

Figure 1.

Types of Ni-kshay Mitra who registered and provided support

Types of Ni-kshay Mitra and engagement to support

At the national level, maximum Ni-kshay Mitras were from the individual category (66%) and most of them were healthcare staff or officers of the health department. The reported data showed that there was limited involvement from political parties and elected representatives with an average 6.5 PwTB adopted per Ni-kshay Mitra. However, corporates, medical institutions, and NGOs promised higher conversion rates for the provision of support (over 50%) compared to other categories. There were 5062 corporates/institutes NGOs/Co-operative supporting 101,603 PwTB (45%) and 26,070 individuals as Ni-kshay Mitra: supporting 68,977 PwTB (30%).

Reach of the PMTBMBA – Engagement status of Ni-kshay Mitra by Geography

Figure 2 shows Uttar Pradesh (27%), Maharashtra (12%), and Uttarakhand (8%) recorded maximum Ni-kshay Mitra registrations (n = 82,205). However, Sikkim (91%), West Bengal (79%), Bihar (77%), and Gujarat (72%) exhibited higher conversion rates to the provision of support (n = 39,015).

Figure 2.

Engagement of Ni-kshay Mitra based on geographical variations

Profile of PwTB under PMTBMBA initiative

Coverage among the consented PwTB

During the analysis, it was observed that 2,152,285 (81.5%) PwTB had agreed to receive the benefits and 252,268 (9.6%) of PwTB had received the benefits out of total 2,641,282. Simultaneously, the analysis revealed that 15,136 (6%) of PwTB had not provided the consent but received the benefits (252,268) which could be due to errors in Ni-kshay data reporting.

The geographical representation revealed that the states have varied rates of actual support provision to persons with TB from Ni-kshay Mitra. Out of 2,641,282 eligible cohorts of PwTB, from across the country, 9.6% (252,268) were documented to receive support in Ni-kshay. Odisha (22%), Gujarat (20%), Himachal Pradesh (17%), Uttarakhand (17%), and Maharashtra (13%) were better-performing states.

Sociodemographic and clinical profile of the PwTB

The analysis was undertaken for characteristics and benefits received among different groups based on the selected cohort of the PwTB [Table 1]. The data variables included information on gender, age distribution, and key population from the notification registers.

Table 1.

Sociodemographic characteristics of PwTB and receipt of PMTBMBA benefits (n=26,41,282)

Sociodemographic and clinical characteristics		Benefits received	%	Benefits not received	%	Total
Gender	Male (%)	131325	8.3	1456328	91.7	1587653
		58.6		60.25		60.1
	Female (%)	92493	8.8	956278	91.2	1048771
		41.27		39.56		39.7
	Transgender (%)	100	9.0	1013	91.0	1113
		0.04		0.04		0.1
	Blank values (%)	189	5.0	3556	95.0	3745
		0.08		0.15		0.1
Age distribution	0-14 years (%)	12927	8.3	143583	91.7	156510
		5.77		5.94		5.9
	15-30 years (%)	79734	8.8	826412	91.2	906146
		35.58		34.19		34.3
	31-60 years (%)	99953	8.4	1086058	91.6	1186011
		44.6		44.93		44.9
	Above 60 years (%)	31493	8.0	361011	92.0	392504
		14.05		14.94		14.9
	Blank values (%)	0	0.0	111	100.0	111
		0		0		0.0
Key population	Yes (%)	99486	9.7	928774	90.3	1028260
		44.39		38.42		38.9
	No (%)	124621	7.7	1488401	92.3	1613022
		55.61		61.58		61.1
TB site	EPTB	56902	8.3	630811	91.7	687713
	(%)	25.39		26.1		26
	PTB	167205	8.6	1786364	91.4	1953569
	(%)	74.61		73.9		74
Case type	New	189951	8.1	2162760	91.9	2352711
	(%)	84.76		89.47		89.1
	PMDT	12021	15.9	63782	84.1	75803
	(%)	5.36		2.64		2.9
	Retreatment recurrent	12755	15.8	68027	84.2	80782
	(%)	5.69		2.81		3.1
	Retreatment after failure	8167	75.4	2669	24.6	10836
	(%)	3.64		0.11		0.4
	Treatment after lost to follow-up	284	3.8	7164	96.2	7448
	(%)	0.13		0.3		0.3
	Retreatment others	929	0.8	112773	99.2	113702
	(%)	0.41		4.67		4.2
Type of diagnostic facility accessed	Public health facility	188725	10.5	1606209	89.5	1794934
	(%)	84.21		66.45		68
	Private chemist	102	3.1	3151	96.9	3253
	(%)	0.05		0.13		0.1
	Private health facility	24413	3.7	638686	96.3	663099
	(%)	10.89		26.42		25.1
	Private laboratory	10378	6	161941	94	172319
	(%)	4.63		6.7		6.5
	Blank	489	6.4	7188	93.6	7677
	(%)	0.22		0.3		0.3
Comorbidity	Diabetes	15764	8.2	177077	91.8	192841
	(%)	7.03		7.33
	HIV	606	7.3	7642	92.7	8248
	(%)	0.27		0.32
Treatment outcome	Cured	42376	9.7	395842	90.3	438218
	(%)	18.91		16.38		16.6
	On treatment	118277	9.3	1149295	90.7	1267572
	(%)	52.78		47.55		48
	Treatment complete	56774	6.8	777702	93.2	834476
	(%)	25.33		32.17		31.6
	Treatment regimen changed	1579	10.2	13939	89.8	15518
	(%)	0.7		0.58		0.6
	Treatment failure	629	9.5	6021	90.5	6650
	(%)	0.28		0.25		0.3
	Lost to follow-up	1001	4.5	21043	95.5	22044
	(%)	0.45		0.87		0.9
	Died	3404	6.6	48241	93.4	51645
	(%)	1.52		2		2
	Others (wrongly diagnosed, untraceable, not evaluated)	67	1.3	5092	98.7	5159
	(%)	0.03		0.21		0.2

The findings revealed that male PwTB received benefits from the program more frequently than other gender categories, with 58.6% of male PwTB benefiting. However, across all gender categories, only 8–9% of PwTB received benefits. Additionally, there were 3745 entries where gender was not specified.

In terms of age distribution, the study categorized PwTB into four groups: 0–14 years (pediatric), 15–30 years, 31–60 years, and above 60 years. The majority of PwTB (45%) fell into the 31–60 years age group. Among this group, 44.6% received benefits from the PMTBMBA program.

Regarding key populations, 1,028,260 PwTB, constituting 39% of the total cohort, were identified. Of these, 99,486 individuals, or 9.7%, were provided with benefits. This analysis highlights the disparities in benefit distribution and underscores areas where improvements could be made to ensure more equitable access to the program’s benefits.

Clinical profile of the PwTB and their status of PMTBMBA benefits

The analysis of PwTB in Table 1 shows that 8.6% of those diagnosed with pulmonary TB received benefits, with 74.5% of them being supported. The majority of PwTB (89%) were newly notified cases, with 84.8% receiving benefits, while retreatment and drug-resistant TB cases also had notable benefit receipt rates. Most PwTB were diagnosed at public health institutes, with 10.4% receiving benefits, accounting for 84.2% of all benefits. Among those with comorbidities, 8% of PwTB with diabetes and 7.3% with HIV received benefits. Overall, 9.3% of those actively on treatment received support, highlighting the program’s varied coverage across different clinical profiles.

Impact of PMTBMBA on persons with TB

Support provision and treatment outcome

The study conducted the regression analysis on the selected cohort of persons with TB (PwTB) who received benefits from Ni-kshay Mitra. The cohort of those PwTB (N = 293,188) who were notified during September, October, and November 2022 (3 months of program initiation) have received treatment outcomes around May 2023. The variables from the notification registers were analyzed to assess the impact of benefits on their treatment outcome.

Treatment outcomes are classified into two categories: favorable and unfavorable. A favorable outcome is when a PwTB has completed their treatment, showed no further symptoms, and has a negative sputum test for TB bacteria, indicating they are cured or have successfully completed treatment. An unfavorable outcome refers to cases where the treatment does not lead to a positive result for the individual, the community, or the program. This includes outcomes such as death, loss to follow-up, treatment failure, changes in the treatment regimen, and other similar situations.

During the analysis, beneficiaries with a Ni-kshay Mitra support (n = 40,255) and not supported (n = 2,52,933) were categorized based on the favorable treatment outcome. The beneficiaries with Ni-kshay Mitra support exhibited (n = 38,451) a significant 5-percentage point improvement in successful TB treatment outcomes (95%), compared to those without one (90%). This finding was affirmed through Chi-square analysis (P value < 0.001, OR = 2.2, CI 2.10 to 2.31) and regression analysis, confirming the statistical significance of the association.

Table 2 summarizes the results of a Multinomial Logistic Regression analysis of factors affecting treatment outcomes, showing a significant model fit (Chi-Square = 6888.264, P = 0.0001) with a Nagelkerke R-Square of 0.053, indicating limited explanatory power; it revealed that lower weight, negative HIV status, certain key populations (e.g., cancer, dialysis), and younger age were associated with more favorable outcomes, while lack of support and not receiving PwTB consent were linked to unfavorable outcomes (Exp (B) =1.671), with the model achieving 100% accuracy in predicting favorable outcomes and 91.5% overall classification accuracy. This beneficial effect was noticed over 9 months with selected cohorts who were diagnosed between September and November 2022 and achieved treatment completion outcomes in Ni-kshay reporting, which suggests positive performance.

Table 2.

Results of multinomial logistic regression to analyze the factors affecting impact on treatment outcome

Model (Final) Chi Sq (P)		6888.264 (0.0001)
Nagelkerke R2		0.053
Parameter estimates
Treatment outcome categorya		B	Std. Error	df	P	Exp (B)	95% Confidence Interval for Exp (B)
							Lower Bound	Upper Bound
Unfavourable	Intercept	0.979	0.324	1	0.002
	Weight	-0.026	0.001	1	0.000	0.974	0.973	0.976
	[Gender=Female]	-0.288	0.309	1	0.350	0.749	0.409	1.372
	[Gender=Male]	0.013	0.309	1	0.965	1.013	0.553	1.856
	[Gender=Transgender]	0b	.	0	.	.	.	.
	[HIVStatusCategory=Negative]	-0.899	0.041	1	0.000	0.407	0.375	0.442
	[HIVStatusCategory=Positive/Reactive]	0b	.	0	.	.	.	.
	[KeyPopulation=Anti-TNF treatment]	-0.257	0.119	1	0.030	0.773	0.613	0.976
	[KeyPopulation=Bronchial Asthma]	-0.202	0.123	1	0.101	0.817	0.642	1.040
	[KeyPopulation=Cancer]	1.067	0.256	1	0.000	2.906	1.760	4.798
	[KeyPopulation=Cardiovascular Disorder]	0.365	0.371	1	0.326	1.440	0.696	2.983
	[KeyPopulation=Contact of Known PwTB]	-0.263	0.058	1	0.000	0.769	0.686	0.861
	[KeyPopulation=COPD]	0.202	0.099	1	0.041	1.223	1.008	1.484
	[KeyPopulation=COVID recovered PwTB]	-0.081	0.307	1	0.792	0.922	0.506	1.683
	[KeyPopulation=Diabetes]	-0.144	0.059	1	0.014	0.866	0.771	0.971
	[KeyPopulation=Dialysis]	1.249	0.253	1	0.000	3.487	2.125	5.721
	[KeyPopulation=Health Care Worker]	-0.400	0.164	1	0.014	0.670	0.486	0.924
	[KeyPopulation=Hypertensive]	-0.259	0.234	1	0.269	0.772	0.488	1.222
	[KeyPopulation=Migrant]	-0.215	0.124	1	0.083	0.807	0.633	1.028
	[KeyPopulation=Miner]	0.273	0.131	1	0.037	1.315	1.016	1.700
	[KeyPopulation=Other]	-0.096	0.032	1	0.003	0.908	0.853	0.967
	[KeyPopulation=Pregnancy]	-0.247	0.515	1	0.631	0.781	0.285	2.142
	[KeyPopulation=Prison]	0.199	0.312	1	0.523	1.220	0.663	2.248
	[KeyPopulation=Renal Impairment]	1.670	0.552	1	0.002	5.310	1.799	15.674
	[KeyPopulation=Silicosis]	-1.036	1.030	1	0.315	0.355	0.047	2.671
	[KeyPopulation=Tobacco]	-0.058	0.040	1	0.147	0.944	0.873	1.021
	[KeyPopulation=Urban Slum]	0b	.	0	.	.	.	.
	[DiabetesStatusCategory=No]	-0.275	0.024	1	0.000	0.760	0.725	0.797
	[DiabetesStatusCategory=Yes]	0b	.	0	.	.	.	.
	[TypeOfCase=New]	-0.932	0.076	1	0.000	0.394	0.339	0.457
	[TypeOfCase=Retreatment: Others]	-0.911	0.081	1	0.000	0.402	0.343	0.471
	[TypeOfCase=Retreatment: Recurrent]	-0.617	0.082	1	0.000	0.540	0.460	0.633
	[TypeOfCase=Retreatment: Treatment after failure]	-0.266	0.164	1	0.106	0.767	0.556	1.058
	[TypeOfCase=Retreatment: Treatment after lost to follow up]	0b	.	0	.	.	.	.
	[SiteOfDisease=Extra Pulmonary]	-0.055	0.018	1	0.002	0.946	0.914	0.980
	[SiteOfDisease=Pulmonary]	0b	.	0	.	.	.	.
	[Consent from PwTB=No]	0.443	0.032	1	0.000	1.558	1.464	1.658
	[Consent from PwTB=Not Approached]	0.483	0.020	1	0.000	1.620	1.558	1.685
	[Consent from PwTB=Yes]	0b	.	0	.	.	.	.
	[Age of PwTB=0 to14 years]	-1.346	0.033	1	0.000	0.260	0.244	0.278
	[Age of PwTB=15 to 30 years]	-0.857	0.021	1	0.000	0.424	0.407	0.442
	[Age of PwTB=31 to 60 years]	-0.422	0.016	1	0.000	0.656	0.635	0.677
	[Age of PwTB=Above 60 Years]	0b	.	0	.	.	.	.
	[PwTB provided Support=No]	0.513	0.023	1	0.000	1.671	1.598	1.747
	[PwTB provided Support=Yes]	0b	.	0	.	.	.	.

DISCUSSION

India’s formidable challenge with TB necessitates innovative and aggressive strategies to mitigate the disease. For better outcomes in the TB care cascade, India has to address operational and socioclinical issues.[18,19] In addition to this, the Ni-kshay Poshan Yojana must effectively accomplish last-mile delivery to guarantee PwTB receive timely support.[20,21] Tackling these problems is essential to improving PwTB outcomes and treatment efficacy, necessitating creative, community-oriented, and effective program management techniques. In current study, the nutritional support under this initiative highlighted the need to enhance its reach to receive contributory effects to successful treatment outcomes. This initiative has yet to explore other support dimensions outlined as per the guidelines, but findings of the study support the more collective efforts will be beneficial to achieve better outcomes. The PMTBMBA, through its Ni-kshay Mitra program, showcases an innovative model for community participation in TB care, recognizing that medical treatment alone is insufficient to overcome the socioeconomic challenges contributing to TB’s persistence and spread.[14,22]

The study’s finding underscores geographical distribution of Ni-kshay Mitra registrations and support provision highlights the disparities in initiative uptake across different states. This uneven geographical reach indicated the necessity of adapting strategies to local contexts and capacities, ensuring equitable access to support services for PwTB nationwide. Furthermore, a regression analysis demonstrating a significant association between Ni-kshay Mitra support and improved TB treatment outcomes reaffirms the importance of comprehensive PwTB support, including nutritional and social support, in enhancing treatment adherence and success. This finding reinforces the critical role of nutritional and social support in TB care, supporting prior research that links improved nutritional status with better TB treatment outcomes.[12,16,23,24,25]

The recent TB Mukt Gram Panchayat program aims to deepen community engagement by empowering community and local leaders to take a proactive role in the elimination of TB.[26,27] The approaches are in accordance with global TB prevention strategies that support incorporating social protection and poverty reduction initiatives into TB care models.[4,28,29] However, the varying conversion rates of registered Ni-kshay Mitras into active support providers highlighted the challenges in mobilizing and sustaining volunteer participation over time. This variation suggests the need for targeted strategies to enhance engagement, particularly among corporates, institutions, NGOs, and other organizations that have demonstrated higher conversion rates. Prior research on community engagement and volunteer motivation in health projects indicated that strategies including consistent training, award schemes, and guaranteeing an in-depth awareness of the initiative’s consequences can increase the number of volunteers.[22,30,31,32]

Incorporating a digital platform within NTEP to manage Ni-kshay Mitra profiles is critical for sustaining participation. As PMTBMBA expands, the process of onboarding agencies and suppliers for efficient local distribution chain management must be streamlined. A digital platform would allow frontline staff to focus more on delivering crucial services while efficiently allocating resources. This self-sustaining platform would ensure service continuity and interactions between stakeholders and reduce reliance on external assistance, thereby enhancing the resilience of the PMTBMBA initiative.

Limitation of the study

The study’s reliance on record-based data introduces potential limitations related to data entry accuracy and completeness. The data entry modules, developed sequentially across different phases, may have led to discrepancies and dropouts in data recording, potentially affecting the integrity of the dataset. Additionally, the study exclusively utilized data reported through the Ni-kshay Portal, which may not encompass the total number of TB cases in India, also thereby limiting the scope of analysis to only those cases captured within this specific reporting framework. This caused limitation to retrieve the information on the variables such as Ni-kshay Poshan Yojana, support during entire TB care cascade, and severity of diseases, which requires primary data collection and validation. Another significant limitation is the regression analysis conducted on notification registers, which lacked information regarding the severity of TB or any comorbidities that may act as a confounding factor. This absence of detailed clinical data restricts a deeper understanding of treatment outcomes as factors such as disease severity and concurrent health conditions can significantly influence PwTB recovery trajectories and success rates.

CONCLUSION

Early successes and challenges in the rollout of the PMTBMBA initiative reveal crucial insights and plans for TB elimination in India and beyond. The initiative’s initial phase emphasizes the need for rigorous monitoring and evaluation to identify effective practices and those that need improvement. A comprehensive evaluation methodology will help the PMTBMBA adapt and improve to meet TB control and elimination challenges. By adding corporate sector and civil society stakeholders to the PMTBMBA program, resource mobilization is expected to increase, boosting its reach and impact. These different sectors bring new ideas, resources, and novel approaches to public health issues, making TB response more dynamic and robust.

The integration of PMTBMBA’s plans with other national health initiatives would improve India’s health care system. Such integration not only simplifies efforts toward TB control but also links them with larger public health objectives, ensuring a more holistic approach to disease prevention and health promotion. Additionally, PMTBMBA’s lessons could be used to create similar health efforts worldwide, especially in high-TB locations. A resilient and effective TB control ecosystem requires PMTBMBA’s continuing evolution, informed by thorough monitoring and evaluation, stakeholder involvement, and integration with broader health programs. As India works toward TB elimination, PMTBMBA’s findings will complement efforts for eliminating TB in India and also showcase as a unique model of community support for the world.

Disclaimer

The US Agency for International Development administers the US foreign assistance program providing economic and humanitarian assistance in more than 80 countries worldwide. This study is made possible by the generous support of the American people through the United States Agency for International Development (USAID). The contents are the responsibility of the authors and do not necessarily reflect the views of USAID or the United States Government.

Author contributions

Conceptualization, HS, JP, BV, SN, AA, DR, YP, AS; Methodology, HS, RR, BV, SN, DS, AS; Software, HS, JP, RS, SR, SP, SC, RDC, DS; Validation, HS, JP, RS, SN, AA, DR; Formal analysis, HS, JP, RS, DR, SR, SP, SC, RDC; Investigation, HS, JP, BV, AA, SR, SP; Resources, HS, RR, BV, AS, SN, DR, YP, SC, DS; Data Curation, HS, JP, RS, AA, SR, YP, SC; Writing - Original Draft, HS, JP, BV, SN, SR, RDC; Writing - Review and Editing, HS, RS, SP, SC; Visualization, HS, JP, BV, SN, YP; Supervision, RR, SN, AA, DR, SC, DS; Project administration, HS, BV, SN, YP, DS; Funding acquisition, HS, JP, DS, SN; All authors critically revised the manuscript for important intellectual. content and all authors gave final approval for the version to be published.

Conflicts of interest

RR is the nodal officer at the country level and monitoring the performance of the initiative. AA and DR, National consultants of PMTBMBA are providing technical support to NTEP for this initiative. The remaining authors are not involved with this initiative directly to oversee its implementation. The authors declare that the research was conducted without any commercial or financial relationships construed as a potential conflict of interest. The analysis presented here is derived from their working experiences in research and TB programme.

We declare no competing interests. The views expressed in this manuscript are those of the authors and do not necessarily represent the official position of the organizations they are affiliated to.

Funding Statement

The study received funding from USAID through IPE Global Limited, under USAID’s flagship initiative in innovative financing in healthcare – Partnerships for Affordable Health Access and Longevity (PAHAL). The staff of the funding agency critically reviewed the draft and offered comments to improve the Manuscript. However, the contents of this article are the sole responsibility of the authors and do not receive any funding for same. It neither reflects the views of Central TB Division, MoHFW, Govt of India, Indian Institute of Public Health, Gandhinagar, IPE Global Limited – Pahal, USAID or the United States Government.