STEPS

The System for TB Elimination in Private Sector (STEPS) model evolved as a solution to address gaps in the quality of care for patients in the private sector by ensuring standards of TB care in India (STCI). STEPS is envisioned as an equal partnership between the public and private sectors for the benefit of society with TB elimination as the outcome.

The primary objective of STEPS is to address gaps in the quality of care for patients in the private sector by ensuring standards of TB care in both sectors to all citizens in a patient-centric manner.

Components of STEPS

1. Establish STEPS centre in each private hospital: These centres act as a single window for notification, linkage for social welfare measures, contact investigation, chemoprophylaxis, direct benefit transfers and treatment adherence support.
2. Consortium of private hospitals: Provides policy and resource support, and reviews the centre's performance.
3. Coalition of all professional medical associations: Sensitizes and supports specialists and doctors, and advocates with doctors for standards for TB care.

Establishing STEPS Centres

• In January 2019, the STEPS model was initiated and piloted in 14 districts in Kerala.
• Establishing STEPS centres at all private and cooperative hospitals is the heart of private sector engagement in Kerala. 
• STEPS centres are single window mechanisms at private hospitals to help doctors and to ensure that all TB patients diagnosed that particular hospital receive high standards of TB care.
• The STEPS centre will coordinate notification and follow up patients till the end of treatment, ensure all public health actions and link them to social welfare measures. 
• Patients will be followed up through an ‘after sales service model’ which is based upon a blend of self-initiated business promotion and customer loyalty blended with the social responsibility of private sector

Functions of STEPS Centres

1. To act as a single window mechanism for all TB-related services in the hospital
2. Notify in Nikshay all TB cases diagnosed in the hospital
3. To guide, support and arrange for:

• Universal Drug Susceptibility Testing (UDST)
• National TB Elimination Programme (NTEP) drugs if required
• Direct Benefit Transfer (DBT) of Rs 500 per month during treatment 
• Provisions for airborne infection control (AIC) kit
• Mobile based adherence monitoring system (99 DOTS) in case of NTEP drugs
• Offer HIV counselling and testing

4. To educate on TB and counsel the patient and family members on the need for completing treatment
5. To educate the patient and family members on AIC, adverse drug reactions (ADRs) and smoking cessation
6. To follow up the patient periodically over the phone to motivate the patient to continue treatment, detect any ADRs, remind about follow up investigations and scheduled clinical visits
7. Update details of bank account, UDST, treatment initiation, co-morbidity and outcome in Nikshay
8. Fast tracking patients with infectious TB as a step to ensure AIC in health facility
9. Ensuring other public health actions including contact tracing, chemoprophylaxis either directly or linking those patients willing to be followed up by the government field staff to local primary health care team
10. Document all activities and submit monthly report to the Private Hospital Cons
11. ortium

Figure: Schematic Representation of STEPS Center Within a Hospital; Source: STEPS: A Solution for Ensuring Standards of TB Care for Patients Reaching Private Hospitals in India; Shibu B et al. 2021

Forming a Private Hospital Consortium

In every district, a consortium of private hospital owners provides policy and resource support for STEPS centers and reviews the STEPS centres' performance. Consortium members select one of the hospitals to serve as chair for a fixed term. The district program manager of NTEP serves as member secretary. The consortium meets once in 3 months to review the performance of STEPS centers and suggest corrective actions if required.

Create a Coalition of Professional Medical Associations

• In all districts, a coalition of professional medical associations advocates with medical practitioners and sensitizes them on STCI and STEPS.
• In addition to the Indian Medical Association, members of the coalition include associations of chest physicians, pediatricians, general physicians, geriatrics, family medicine, nephrologists, general surgeons, orthopedic surgeons, and radiologists.
• The coalition meets every 3 months to plan and review the activities as per the plan.

Initial Results of STEPS

• Since its pilot, TB patient notification to NTEP from the private sector in Kerala has increased. Also, public health actions, such as Direct Benefit Transfer (DBT), Universal Drug Susceptibility Testing (UDST), HIV testing, etc., for patients diagnosed from the private sector has increased.
• STEPS led to a shift from using private anti-TB drugs to NTEP-supplied drugs, leading to 2,000 additional cases being put on NTEP-supplied drugs. Overall, 70% of all cases notified from the private sector in 2019 were treated with NTEP-supplied drugs.
• Data officially collected by the state drug controller showed that the sale of anti-TB drugs decreased from 1.6 million rifampicin units in 2018 to 0.5 million rifampicin units in 2019 after the establishment of the STEPS model.
• Qualitative feedback also showed that STEPS was an acceptable m
• odel to all stakeholders, and patients were satisfied with the services received. During COVID-19, STEPS was resilient enough to ensure TB patient services and facilitate partnerships for COVID-19 management.

Resources

• Guidance Document on STEPS (System for TB Elimination in Private Sector) in Kerala.
• STEPS – A Patient-centric and Low-cost Solution to ensure Standards of TB Care to Patients Reaching Private Sector in India, Rakesh, P.S., Balakrishnan, S., Sunilkumar, M. et al, BMC Health Services Research, 2022.
• STEPS: A Solution for Ensuring Standards of TB Care for Patients Reaching Private Hospitals in India, Shibu Balakrishnan, Rakesh PS, et al., Global Health: Science and Practice, June 2021.

Assessment