Involvement of non-governmental organisations in the RNTCP

To get the maximum benefit from Revised National TB Control Programme (RNTCP) developing partnership with private health providers outside government health system is very important. RNTCP actively seeks the participation of the NGOs by sensitising them with DOTS strategy. A broad framework for involvement of NGOs has been evolved by RNTCP Schemes for NGOs and RNTCP collaboration are elaborated. Over 514 NGOs are currently participating in the programme under one or another scheme. In addition to the guidelines developed by Government of India, innovative forms of partnership between RNTCP, NGOs and other private health providers should be encouraged.     

Challenges for the RNTCP in India

Tuberculosis has been a public health problem in India since time immemorial. The disease has a devastating socio-economic cost in India, with over 450,000 people dying of TB each year--1000 every day, 1 every minute. To control the menace, Revised National TB Control Programme (RNTCP) was implemented starting in October, 1993. Around 1.6 million TB cases have been placed on treatment under RNTCP since its inception, saving over 290,000 lives. The first and foremost challenge to RNTCP is covering the entire country so that benefits are available to all Indians. Planning for nationwide coverage by 2005 for maintaining high quality of TB services is a major challenge while undertaking a rapid expansion of RNTCP Another challenge is acute shortage of manpower. Decentralisation of programme management for effective administration and sustainability of the programme to the states is another challenge. Other sectors like NGO, private practitioners Railways, ESI scheme, Medical Colleges, health care providers are to be involved in RNTCP. Despite these challenges RNTCP is performing very well. DOTS is the best available strategy for curing TB patients and that all the elements of DOTS must be adopted both in letter and in spirit.     

Status report on DOTS expansion and implementation during the 4th quarter 2003

Performance of RNTCP involvement of medical colleges in implementing DOTS strategy, management of paediatric TB under RNTCP, TB/HIV co-ordination, external quality assurance, training of staff, strengthening of ICE, monitoring, supervision and collaboration with other sectors are briefly discussed with regard to DOTS expansion and implementation during the 4th quarter, 2003.     

The public-private mix in India's Revised National Tuberculosis Control Programme--an update

The Revised National TB Control Programme (RNTCP) in India has made definite progress over the last 2 years and given a boost to global DOTS expansion. The Private Practitioners (PPs) involved in Public-Private Mix (PPM) in India's RNTCP are the first point of contact for more than 2/3rds of TB symptomatics. The vital components of PPM approach are supervision and monitoring of diagnosis of referred cases from PPs, functioning of private laboratories, registration of confirmed cases, treatment with DOT and documentation. The most important contribution of some of the PPM projects has been the creation of a link in the form of a referral system between the private and public sectors. PPM can contribute positively to the performance of RNTCP. RNTCP should be seen as the first step towards an exciting direction in engaging private sector in public health programmes.     

Status report of the Revised National Tuberculosis Control Programme: January 2003

Tuberculosis (TB) remains a serious public health problem in spite of DOTS programme recommended by WHO. One person dies from TB in India every minute. Revised National TB Control Programme (RNTCP) is playing a major role in global DOTS expansion. DOTS coverage has expanded from 2% of the population in mid-1998 to 57% by the end of January, 2003. RNTCP has made a significant contribution to public health capacity. The programme has saved the people of India hundreds of millions of dollars. Monitoring the clinical course using smear microscopy and accurately reporting treatment outcomes is essential in well-functioning DOTS programme. RNTCP has invested heavily and made significant strides in maintaining and improving quality DOTS. State and district level programme reviews are a key component of the process. RNTCP has established guidelines for the involvement of the private sector and medical colleges. A member by ongoing technical activities will improve RNTCP's surveillance and monitoring systems. However a challenge lies with the programme and a collective effort is welcome.     

RNTCP 2007: looking ahead to future challenges

The largest TB control programme in terms of patients treated is India's Revised National Tuberculosis Control Programme (RNTCP). The treatment success of new smear positive TB cases under RNTCP has exceeded the global benchmark of 85%. Also there are some challenges in TB control programme eg, addressing TB in HIV-infected persons and accurate diagnosis and management of multidrug resistant TB (MDR-TB). Diagnosis of MDR-TB requires sophisticated laboratories. If MDR-TB is not managed effectively, then there is possibility to emerge drug-resistant TB which is virtually untreatable. The Public-Private mix initiatives of RNTCP attempt to make quality assured treatment for TB for all patients, regardless of healthcare providers they choose. The International Standards of TB Care (ISTC) is an international effort which has articulated the diagnostic, treatment and public health standards which all providers should hold themselves and their peers accountable to. For providers the path to practise the ISTC is to diagnose and treat patients in collaboration with RNTCP. The IMA has taken up the cause of TB control in India very seriously. This organisation of the doctors (IMA) deserves recognition for becoming the first professional association to endorse the ISTC in India. All health providers should work with and support the RNTCP, so that the programme can be made into a genuine mass movement to fight TB.     

Medical colleges' involvement in the RNTCP: current status

To widen access and improving the quality of TB services, involvement of medical colleges and their hospitals is paramount. The role of medical college professors in TB control as opinion leaders and role models for practising physician and as teachers imparting knowledge and skills and shaping the attitude of medical students cannot be underestimated. There is a pressing need for all medical schools to advocate DOTS and through this strategy provide the best opportunity for cure of patients. Priority activities to be undertaken by medical colleges are: (1) Training and teaching of RNTCP. (2) Service delivery of the RNTCP. (3) Advocacy of the RNTCP. (4) Operational research. A National Tast Force is being constituted comprising representatives from the zonal nodal centers, Central TB Institutes, and Central TB Division. With the establishment of zonal nodal centres and task forces at the different levels, it is envisaged that the movement will gain further momentum.     

Role of community volunteers in the RNTCP

Community volunteers (CVs) along with NGOs and private sector can play an important role in successful directly observed treatment (DOT), an important element of RNTCP. The involvement of CVs can be useful in areas with poor health structure. CVs can be recruited from housewives to chowkiders in all walks of life. Many studies have shown non-health workers have performed better supervision than health workers. Successful involvement of CVs in the RNTCP depends on supervision and the standard of quality of services set by the district programme.     

Involvement of private practitioners in RNTCP

Private Practitioners are often the first point of conduct for a significant proportion of TB patients. For long-term success of RNTCP involvement of them is very essential. All Private Practitioners can support and encourage effective TB control by ensuring prompt referral, providing reassurance to patients, giving RNTCP recommended drug regimens and only starting treatment with rifampicin containing regimens if the full course of treatment can be ensured to be completed under direct observation. Schemes for Private Practitioners' involvement in RNTCP are: Scheme 1 referral services, scheme 2 provision of Directly Observed Treatment, scheme 3a designated MC--microscopy only, scheme 3b designated paid MC-microscopy and treatment, scheme 4a designated MC-microscopy only, scheme 4 b designated MC-microscopy and treatment. Nationwide Public--Private Mix (PPM) services involving 1500 private practitioners are providing RNTCP services successfully.     

IMA GFATM RNTCP PPM project: milestones in sight one year after

The IMA GFATM RNTCP PPM has completed its one year journey on 31-03-2008 and gaining the momentum. The IMA's three-tier administrative structure looks after the Project Implementation Plan (PIP) at all levels. At the end of first year, the PIP has come up to the satisfaction of all. The indicators of success have been tabulated and reproduced in this article. The objectives, targets of 'stop tuberculosis' strategy by 2050 has been mentioned to inform that less than 1 case per million population per year will no longer be a public health problem. What is public-private mix and how it enhances the quality of diagnosis and takes treatment convenient for patients is also being elaborated. Scientific bases of intermittent regimen of DOTS are also effective and this forms the rationale of the usage of the thrice-weekly regimens recommended in the RNTCP.     

Role of laboratory in RNTCP

Tuberculosis (TB) remains a major public health problem in many parts of the world. Sputum smear microscopy is the mainstay of diagnosis of TB. RNTCP follows the international guidelines which recommend the establishment of microscopy centre for every 100,000 population. All patients with a cough of three weeks or more should undergo 3 sputum diagnostic examinations for acid-fast bacilli (AFB). A separate TB laboratory register is maintained in each microscopy centre. Disposal of laboratory waste should be destroyed. One slide from each patient is sent to the District TB Centre (DTC) for external quality assurance (EQA). The activities of the microscopy centres in a TB unit are supervised by a Senior TB Laboratory Supervisor (STLS). The STLS visits every microscopy centre at least once a month. Sputum samples from patients who fail RNTCP treatment are sent to the nearest reference laboratory for culture of M. tuberculosis and drug susceptibility testing; however there is no need to send patient samples routinely for culture.     

A comparative study of status of RNTCP in tribal and non-tribal districts of Odisha

To compare the RNTCP outreach in the tribal districts with that of non-tribal districts. The annual status reports on RNTCP was analysed to evaluate the performance in tribal districts and non-tribal districts. The case detection parameters were far better in the tribal districts than in the non-tribal districts. Treatment success was almost equal in the tribal districts to that of non-tribal districts.     

Health policy, systems and services research and the Revised National Tuberculosis Control Programme

Directly Observed Treatment, Short-course (DOTS) has become the accepted standard for diagnosis, treatment and monitoring of tuberculosis (TB) worldwide. DOTS is the best treatment strategy available today, but it does not and cannot remain static. Health policy, systems and services research (HPSSR) described in the context of TB control, offers significant gains at relatively low cost and in a shorter timeframe. A rational framework is necessary to develop a research agenda and select priorities, especially when resources are limited. India has adopted, adapted and implemented DOTS strategy as the RNTCP. RNTCP has a clear set of programme objective ie, (a) cure of at least 85% of registered new smear positive pulmonary TB (NSP) cases and (b) detection of at least 70% of estimated NSP cases existing in the community. The RNTCP must be supported by research that continuously provides better tools for diagnosis, treatment and monitoring.     

Ethical aspects of the Revised National Tuberculosis Control Programme

This paper identifies some ethical concerns regarding the Revised National Tuberculosis Control Programme (RNTCP). Only 10% of those with chest symptoms visiting public health facilities get specific treatment as they are diagnosed with TB. The remaining 90% who suffer from non-TB diseases are not given scientific treatment. This compartmental approach denies treatment to millions of people with chest symptoms. It has also eroded the popularity of public health facilities. Second, though 87% of those diagnosed on the basis of x-ray alone are unlikely to have TB, such unethical wrong diagnoses continue to be carried out under the TB programme. Still worse, the RNTCP's expectation that only half of TB cases should be smear positive effectively permits up to 50% of diagnoses to be wrong. The actual extent of wrong diagnosis is even higher as the majority of people with chest symptoms first visit private health facilities which base their diagnosis almost exclusively on radiological examination. Third, though 25% to 33% of TB cases get cured spontaneously, and at least two-thirds were cured even with incomplete treatment, the RNTCP insists on full treatment for all TB cases. This over-treatment is unethical, wasteful and also tantamount to scientific dishonesty. Studies to identify different categories of cases (those needing full treatment, short treatment or no treatment) have not been attempted. The introduction (under the RNTCP) of the "success rate"in preference to the well recognised "cure rate" was unethical and unwarranted. "Crying wolf" over Multiple Drug Resistant (MDR) TB to justify DOTS when there is no apparent alarming increase in the incidence of initial MDR tuberculosis cases is also questionable. Other ethical concerns about the RNTCP include the irrational choice of districts leading to exclusion of those that need the services most; exclusion of diagnosed patients from the DOTS scheme, and exclusion from treatment on non-medical grounds. Such exclusions can be up to 58% of TB cases.     

HIV/TB in India: a public health challenge

The impact of HIV/AIDS epidemic on the epidemiology of TB worldwide is being noted with growing concern. Patients with HIV are more susceptible to opportunistic diseases including TB. The risk of development of TB in HIV-infected patients in India is 6.9/100 person-years compared to a 10% lifetime risk of developing TB in an HIV negative individual with Mycobacterium tuberculosis. Treatment with DOTS significantly prolongs the life of HIV-infected persons with TB. The Government of India emphasised the need for strengthening collaboration between TB and AIDS control programmes for better management of HIV-infected patients with TB. Areas with higher prevalence of HIV infection have been prioritised the RNTCP coverage and most are already implementing the RNTCP. The basic purpose of HIV-TB programme co-ordination is to ensure optimal synergy between the two programmes for prevention and control of both the diseases.     

IMA GFATM RNTCP PPM JIMR DOTS project

Government of India and Stop TB Partnership strongly feel that Public Private Mix is reaquired to achieve the desired results of eliminating TB as a public health problem by 2050. IMA has accepted and adopted the DOTS strategy of RNTCP. Project Implementation Plan of IMA and GFATM is narrated for the readers to understand IMA GFATM RNTCP PPM. The goal is to achieve to bring down the burden of TB in India till it ceases to be a public health problem. In this project IMA has choosen to carry out intensified activities in five states and one union territory in India. With the idea, expected outcomes can be categorised at 3 levels--national, state and district. The individuals of IMA leadership will provide services on an honorary basis, so that the project can be best implemented in its truest sense.     

Role of WHO recruited consultants in successful implementation and expansion of the DOTS programme in India

For successful implementation of DOTS in India, many factors have played important part and one of which is the use of WHO-contracted local consultants. WHO had recruited consultants known as RNTCP Medical Consultants (RMCs) and assigned them to States and districts to provide technical assistance to the State and District TB Officers. In the districts the RMCs assist in preparation of action plans and interact with district and State authorities. The RMC network is funded by WHO and the Canadian International Development Agency. The assignment of RMCs has resulted in much more rapid implementation of the DOTS strategy with sustainable improvement in the quality of the programme in implementing districts.     

An overview/update IMA GFATM RNTCP PPM project

The existence of tuberculosis (TB) can be found in the bones of prehistoric man, found in Germany. Hippocrates (460-377 BC) also gave some imputs regarding the age-old TB. As regarding TB control history, some drugs were advised, but those drugs appear funny to present day physicians. Organised efforts to combat TB came into origin in late 1930s. In phase I establishment of sanatoria and TB clinics came into existence, then TB Association of India came into the picture, followed with direct initiative by the government. Phase II dealt with three decades of the National TB Control Programme. WHO declared TB is a global emergency. RNTCP is an application of WHO recommended DOTS strategy. Full implementation of the DOTS strategy remains the priority to control TB. Performance of RNTCP is more than statistactory.     

Health seeking behaviour of tuberculosis patients--role of the private practitioner

India accounts for nearly 30% of the global tuberculosis burden. The goal of the Revised National TB Control Programme (RNTCP) is to cure at least 85% of new smear positive cases of TB and detect at least 75% of such patients. There are many reasons for patient delaying seeking healthcare. A Private Practitioner plays a major role in combating the disease but unfortunately the doctor-delay is more than patient-delay. Still patients seem to prefer Private Practitioners and they are often the first point of contact for a significant number of patients with TB.     

History of tuberculosis control in India

TheTB problem in India was first recognised through a resolution passed in the All India Sanitary Conference, held at Madras in 1912. The TB picture started becoming clear with the introduction of tuberculin testing. The Bhore committee report issued in 1946 estimated that about 2.5 million patients required treatment in the country with only 6,000 beds available. The first open air institution for isolation and treatment of TB patients was started in 1906 in Tilaunia near Ajmer and Almora in the Himalayas in 1908. The anti-TB movement in the country gained momentum with the TB Association of India was established in 1939. WHO and UNICEF took keen interest in providing assistance for introducing mass BCG vaccination with low cost in 1951. In the 1940s streptomycin and PAS were introduced in the west followed by thiocetazone and INH is 1950s. National Tuberculosis Control Programme (NTP) was formulated in 1962 which was implemented in phased manner. The deficiency in NTP was identified in 1963 and Revised National TB Control Programme (RNTCP) was developed. There is a commitment for Government of India to expand RNTCP to cover the entire country by 2005.