Strategic Leverage Points in Implementing India's Nikshay Poshan Yojana for Tuberculosis Patients: A Scoping Review

Tuberculosis (TB) continues to pose a major public health challenge in India. Malnutrition critically worsens clinical outcomes in patients with tuberculosis. The Nikshay Poshan Yojana (NPY), a national direct benefit transfer (DBT) scheme in India, provides monthly nutritional support to TB patients. The NPY is a flagship program that plays a significant role in India's fight against TB, and its success depends on effective implementation. This scoping review synthesizes evidence on NPY implementation challenges and possible solutions and models their interconnections using a network approach. Leverage points that can enhance the program's performance are identified through network analysis and quantified via centrality metrics. Following a systematic search of relevant databases, 16 primary research studies evaluating the implementation of NPY were included in the synthesis. Qualitative findings on barriers and solutions were thematically synthesized and modeled as a network, with nodes representing the identified themes and edges indicating the co-occurrence of themes across studies. Degree and betweenness centrality measures identified key leverage points. Four main barrier categories were identified and thematically synthesized: administrative/procedural, financial/banking, patient-level, and healthcare system/provider. These contributed to significant payment delays (median: 43 days to 5.2 months). The network analysis revealed that "lack of bank accounts" was a highly central barrier (degree: 1.0000). Patients' health status also emerged as a critical bridging challenge (betweenness: 0.0604). The key solutions identified included simplifying banking and NPY processes (degree: 0.9286) and implementing a more robust monitoring and evaluation system (betweenness: 0.0482). Interventions targeted at these key leverage points, focusing on improved banking access, streamlined processes, and a strengthened health system, could potentially improve program implementation.