National Framework for a Gender-Responsive approach to TB in India

Tuberculosis (TB) affects an estimated 10 million people globally every year, of which around 3.2 million are women. India has the world’s highest annual incidence of TB as well as the highest TB-related mortality. Although more men are affected by TB, women and transgender persons experience the disease differently.

Gender differences and inequalities play a significant role in how people of all genders access and receive healthcare in the public and private sectors. There is adequate evidence to indicate that gender is a significant influencer of the epidemiology, risk factors, probability of diagnosis, access to healthcare, treatment adherence and overall impact of TB on communities.

A gendered approach to TB care and prevention is a felt need in the Revised National Tuberculosis Control Programme (RNTCP) for which a framework has been developed.

About the framework

The framework reflects the interactions between TB and gender at various levels, and aims to:

• Outline the influences and impact of gender on the TB burden and response, based on available literature and data;
• Define actions which would help move towards a gender-responsive approach;</li.
• Provide guidance to implement these actions.

The framework is in keeping with the National Strategic Plan for TB for 2017-2025 and is intended to spark dialogue at all levels within the TB programme and among key stakeholders, thereby strengthening the collective understanding of TB and gender.

Gender as a determinant for TB

Gender differences in incidence of TB:

A higher proportion of the 27.4 lakh diagnosed with TB in India are men and the ratio is approximately 2:1 (Global TB Report 2018) between men and women. Multiple studies on the incidence of TB across the country indicate that more men report microbiologically confirmed pulmonary TB and women are more likely to have clinically diagnosed pulmonary TB and extra-pulmonary forms of TB. Research shows that the prevalence of HIV-TB co-infection is higher among women and among transgender persons who live in overcrowded houses and consume alcohol. Pregnant women and women in the postpartum period face a higher risk of TB and TB is one of the leading non-obstetric causes of maternal mortality in low-income countries like India.

Gender differences in exposure, risks and vulnerability:

Women are especially constrained by social norms which prevent prioritising of their nutrition, health and wellbeing. Undernutrition, their role as caretakers and the use of solid fuel for cooking puts women at risk for TB. While alcoholism and smoking among women is poorly accepted, these behaviours may be condoned or even encouraged as a result of the prevailing gender norms for men. Smoking and alcohol consumption are therefore specific gender-linked barriers to TB diagnosis and treatment for men. Men are at greater risk of developing TB due to their employment in mining, quarrying, metals and construction industries. Transgender persons often have low literacy, low education levels and are poor. A high proportion of transgender persons are known to smoke, consume alcohol and use drugs. All these factors make them vulnerable to TB.

Gender differences in health seeking and health system factors:

While the fear of loss of income and the consequences of absence from work hinder careseeking in women, men face difficulties due to perceived stigma, prioritisation of household chores, lack of money or financial dependence. Poor health literacy and fear of criminalisation hinders transgender persons from seeking care. Besides gender differences influencing care-seeking, health system factors such as limited access, lower index of suspicion of TB for women and provision of inadequate information to care-seekers also significantly affect the access to services across all genders.

Gender differences in treatment outcomes:

Traditionally, women tend to have better adherence and treatment outcomes as compared to men. The pressure to get back to work and lifestyle habits such as smoking or consumption of alcohol influence discontinuation of treatment in men. Migrant workers, mostly men, often face difficulties in adherence to treatment in the face of extreme poverty and issues of daily survival. Stigma and discrimination are major impediments to treatment adherence, mainly among unmarried women, newly married women and the elderly.

National Framework for a Gender-Responsive Approach to TB

The overall framework is based on the principles of non-discrimination, informed choice, informed consent, confidentiality, respect for all, access for all, working in partnership, promoting rights of individuals and groups, fostering accountability and empowering communities.

The framework deals with interventions under the heads of Detect, Treat, Prevent and Build. It also outlines potential gender-responsive interventions under public and private sectors as well as by and with communities.

Detect:

Actions proposed will include training of RNTCP staff in the public sector and private providers on gender differences along the diagnostic pathway between women, men and transgender persons. The programme will ensure that Active Case Finding (ACF) teams are trained on gender-responsive questioning and that the fundamental principle of ‘do no harm’ is conveyed during training. The programme will also strengthen the involvement of TB Champions and survivor led networks to improve care-seeking behaviour among all groups, especially women and transgender persons.

Treat:

Key actions will include orienting health workers on adopting a respectful attitude, respecting the need for confidentiality, improving treatment literacy and providing gender-responsive counselling. Private sector providers will be trained on the need for gendered adherence support and TB Champions and survivor-led networks will be involved for the provision of gendered psychosocial support.

Prevent: 

Women and caregivers will be involved to strengthen contact screening and chemoprophylaxis; periodic screening of health workers for TB will be undertaken; involvement of communities in prevention drives will be strengthened.

Build:

The emphasis will be on building the capacity of the programme and the private sector to provide gendered, comprehensive, patient-centric care. Promoting gender representativeness among survivor-led networks will be a priority.

The framework will guide the programme to mobilise, empower and engage women, men and transgender persons in the TB response at the health system and community levels. Once implemented, the framework envisages a gender-responsive programme which will catalyse and accelerate efforts to end TB in India.

How to use this framework

This framework is intended for programme managers, healthcare providers at the district, state and national levels in the RNTCP as well as for civil society and community representatives, programme managers and healthcare providers involved in provision and evaluation of TB care services in the not-for-profit and private sectors. This framework can be used to:

• Understand the elements of a genderresponsive approach to TB;
• Train health providers and staff on providing gender-responsive care and support along the care cascade;
• Assess and improve the gender sensitivity of services and service providers.

To access the complete national framework, click here.

Source : Central TB Division, Ministry of Health and Family Welfare