Tuberculosis (TB) Safe Families: A Community Approach in India
Summary
In 2024, the Clinton Health Access Initiative (CHAI) and GiveWell committed to launch a new initiative to improve equitable access to tuberculosis preventive services for young children. The initial implementation of this effort is planned for the Indian states of Bihar and Uttar Pradesh which have among the highest pediatric TB burdens in the world.
Through this effort, CHAI and Givewell will reach an estimated 250,000 children by 2029. Additionally, approximately 35,000 community health workers and 2,000 physicians will receive training and support to deliver screening and care during home visits. The organizations will commission an independent cluster-randomized controlled trial to generate evidence on program efficacy and inform future expansion of the program, both in India and to other countries.
This commitment is part of the Maximum Impact Incubator, an innovative partnership between CHAI and GiveWell that uses evidence and data to launch new, impactful, and cost-effective programs that address health inequities.
Approach
An innovative, new project from the Clinton Health Access Initiative’s Maximum Impact Incubator, funded by GiveWell, aims to address pediatric TB through community-based programming that provides access to preventive treatment for children within the community, with the goal of reaching 250,000 children by 2029.
The project is planned in the Indian states of Bihar and Uttar Pradesh—which, given their large populations, have among the highest pediatric TB burdens in the world.
The program will support community health workers (CHWs) to go to homes with someone who has already been diagnosed with TB. They will screen other household members for TB and refer householder members over five years to local health facilities for preventive or therapeutic treatment where indicated. For children under-five, CHWs will offer caregivers the opportunity to put their children on a new preventive treatment called 3HP on the spot. The regimen is significantly less burdensome, with a once-a-week pill taken for 12 weeks.
The Clinton Health Access Initiative (CHAI) and its affiliates/partners will train and monitor approximately 35,000 community health workers to deliver screening and recommend care during home visits, and 2,000 physicians. The organization will provide financial incentives to private sector workers and technical assistance to district and state public health workers to support service delivery. At the project’s end, the goal is to transition the program to government ownership and explore future programming with GiveWell.
To ensure sustainability, CHAI and its affiliates will also leverage the organization’s extensive experience in market shaping to ensure necessary commodities are available and affordable. This includes undertaking a first round of procurement of pediatric 3HP medication, with a view to catalyzing procurement from other parties in the future, and technical assistance to co-package the medications which are part of 3HP. CHAI has already made substantial strides in market shaping for 3HP, such as supporting the development and commercialization of affordable, quality assured adult and pediatric formulations under the Unitaid-funded, Aurum-led IMPAACT4TB program, which will be built upon.
As part of the project, the organization will commission an independent cluster-randomized controlled trial—the best research method to evaluate a program’s impact. The trial will generate evidence on program efficacy and inform future expansion of the program, both nationally and to other countries.
Action Plan
Preparatory phase: 2024-2026
Formalize collaborations with the government
Design evaluation and confirm necessary regulatory approvals
Initiate market-shaping activities—including price negotiation, procurement, and creation of co-packed medications.
2026
Q1-Q2: Baseline data collection in 70 districts, followed by program rollout in 35 of the program’s districts (with the other 35 serving as a comparison group) .
2026-2029:
Q3 2026 – Q3 2028: Program rollout
This will initially consist of capacity building and training activities with community health workers, followed by household visits. Program rollout will be accompanied by a robust monitoring and evaluation strategy to track program implementation which measures program efficacy using key indicators, focusing on equity among the beneficiary population.
Q3-Q4 2028: Endline data collection
CHAI, GiveWell, and IDInsight to compare the districts where the program was rolled out against those where the program was not rolled out.
Q4 2028 – 2029: Rollout of program in the remaining 35 districts
Findings to be disseminated widely.
Background
Tuberculosis (TB) is the world’s deadliest infectious disease (though briefly eclipsed by COVID-19) . Around 10.6 million people fall ill with TB every year, and about 1.6 million people die from the disease (WHO) . India, given its large population, has the highest TB burden in the world, with one person infected every 11 seconds and two people dying of TB every three minutes (WHO) . Children under five account for more than 10 percent of all TB deaths globally (WHO) .
While many people who are infected with TB will not have any symptoms, one in ten will progress to active, symptomatic TB disease. TB is spread through the air when a person with TB disease coughs or sneezes. As a result, people who live in the same home as a person with TB disease are at particular risk of infection. This is especially true for young children, who are vulnerable to developing active disease, and are at higher risk of TB related death.
The current standard-of-care for preventing TB among child household contacts of TB patients is extremely cumbersome. First, caregivers who suspect their child has been exposed must visit a health center for screening, then they put their child on a preventive drug treatment, which generally constitutes a daily drug regimen for six months. For families who need to travel many miles to the nearest TB clinic or take an unpaid day off work, this may not always be possible.
Progress Update
Partnership Opportunities
This innovative program combines the existing, robust community health worker infrastructure in India with an optimal new TB medication for children, to meet people at risk of TB disease where they are – in the community. This has never been performed at this scale while engaging existing community health care systems. In addition, this program includes a robust evaluation, showcasing a steadfast dedication to evidence and data.
The organizations would like to draw attention to this approach to program development—a careful consideration of data and facts to develop a well-planned approach to a challenging problem, coupled with a thoughtful evaluation to provide feedback loops and opportunities to learn and improve.
Additionally, if the results of the randomized control trial are promising, the organizations will seek additional partnerships to scale up the work globally, which will require up to $200 million worth of additional investments., This program could set a global new best practice in preventing the spread of TB. The randomized control trial and process evaluation will help the Clinton Health Access Initiative and GiveWell understand the program’s impact. If the results confirm the promise the organizations see in this new approach, the program could be scaled and implemented more widely both in India and other countries. The organizations are excited to share best practices, lessons learned from the experience, as well as their technical expertise in program execution more widely.