Review of the programme is an ongoing activity, which is being done regularly. The World Bank reviews the programme biannually along with other donor partners. The last World Bank review mission came in December 2007. In addition, the programme is reviewed externally every three years by Joint Monitoring Mission comprising of international experts from WHO, International Union Against TB and Lung Diseases (IUATLD), World Bank, DFID, Netherlands TB Association and CDC, Atlanta etc. Such reviews took place in the years 2000, 2003 and 2006
The latest World Bank review in December 2007, observed that with case detection and treatment success rate at 70% and 84% respectively, Revised National TB Control Programme (RNTCP) has almost achieved the global targets of 70% case detection and 85% treatment outcome of smear positive cases. This highly satisfactory result is a proof of the professionalism and dedication of RNTCP staff. The overall progress needs now to be sustained and more attention should be devoted to poor performing districts / states still below targets. RNTCP has also made commendable progress in challenging areas like TB/HIV collaboration where a good referral system has now been put in place. The institutional strengthening process in Central TB Division is proceeding well and collaboration with the National Rural Health Mission (NRHM) is bearing fruit
The targets fixed by the Government during the 10th plan period for the National TB Control Programme have been achieved. Entire country has been covered under DOTS Strategy by March 2006. The international Joint Monitoring Mission (JMM) in October 2006, has hailed it as the fastest expansion of DOTS in the world. The target and achievements of case detection and cure rates in 10th five year plan can be seen at Annexure. The performance of the programme and its impact is being monitored regularly. Till date, the RNTCP has placed more than 82 lacs patients on treatment thus saving more than 14 lacs additional lives. As per the WHO report 2007, the death rates due to TB have declined from 42 per 100,000 population in 1990 to 29 per 100,000 population in 2005 and prevalence of tuberculosis (old and new cases) has declined from 570 cases per 100,000 population in 1990 to 299 cases per 100,000 population in 2005. Involvement of more than 260 medical colleges, more than 2500 NGO’s, 150 corporate health facilities and more than 18000 private practitioners in the implementation of RNTCP, has increased the access of programme services. The programme is well on its way to achieve MDGs (Millennium Development Goals) related to tuberculosis.
This information was given by the Minister for Health & Family Welfare, Dr. Anbumani Ramadoss in a reply to a question in the Lok Sabha.
In 1992, the Government
of India, together with the World Health
Organization (WHO) and Swedish International
Development Agency (SIDA), reviewed the
National TB Programme and concluded that
it suffered from managerial weakness, inadequate
funding, over-reliance on x-ray, non-standard
treatment regimens, low rates of treatment
completion, and lack of systematic information
on treatment outcomes. Programme review
showed that only 30% of patients were diagnosed
and only 30% of those treated successfully.
Based on the findings and recommendations
of the review in 1992, the GOI evolved a
revised strategy and launched the Revised
National TB Control Programme (RNTCP) in
the country. Starting in October 1993, the
RNTCP was implemented in a population of
2.35 million in 5 sites in different states
(Delhi, Kerala, West Bengal, Maharashtra,
and Gujarat). The programme was expanded
to a population of 13.85 million in 1995
and 16 million in 1996. Having proved both
its technical and operational feasibility,
a soft loan of US $ 142 million was negotiated
with the World Bank in December 1996 and
the credit agreement was signed with IDA
in May 1997. It was envisaged to implement
RNTCP in 102 districts of the country covering
a population of 271 million in a phased
manner. Another 203 SCC districts with a
population of 447 million were envisaged
to be strengthened as a transitional step
for introduction of revised strategy at
a later stage.
Having started in 1997,
rapid scale-up began in late 1998, when
another 100 million populations was covered
under RNTCP. In the past years RNTCP has
been expanding rapidly as shown below:
Year
1998
1999
2000
2001
2002
2003
2004
June
2005
Population
Covered *
18
130
287
450
530
775
947
1028
*
Cumulative, in millions
Starting
in 1997, the project is being implemented
in a phased manner to ensure that quality
of services is maintained. Currently, more
than 90% of the country’s population
has been covered under the programme.
In early 2002, the TB control
project was extended for another 2 years
within the same budgetary provision to cover
700 million populations by 2004 under World
Bank Assistance. The project is further
extended for a year till September 2005
to enable coverage of the whole country
as per schedule. In addition to the above,
DFID and DANIDA are supporting the RNTCP
to cover the entire states of Andhra Pradesh
and Orissa. Global Fund for AIDS, Tuberculosis
and Malaria (GFATM) are supporting DOTS
expansion in 3 States of Jharkhand, Chhattisgarh,
and Uttaranchal (56 million populations).
In addition, the second round of GFATM covers
the remaining 56 districts of Bihar and
Uttar Pradesh with a population of 110 million
and the fourth round of GFATM will be supporting
RNTCP implementation in the states of Andhra
Pradesh and Orissa once the support from
DFID and DANIDA ceases. The Global Drug
Facility (GDF) is providing anti-TB drugs
as commodity grant for 200 million populations.
By September 2005, 604
districts/reporting units are implementing
the RNTCP. 33 States and Union Territories
are fully covered under the programme. GOI
is continuing to take aggressive steps to
meet global TB control targets by covering
the entire country with RNTCP by the year
2005.
Revised
National TB Control Programme and its recent
progress in DOT expansion has been encouraging.
As per Global TB Report 2003, 2/3rd of the
additional sputum positive cases reported
under DOTS in 2001, were found in India.
In 2002, over 620,000 cases were placed
on treatment of which nearly 250,000 were
new smear positive cases. In the year 2003,
more than 900,000 cases were placed on treatment.
In the year 2004 alone more than 1100,000
cases were placed on treatment - largest
cohort of cases, more than any other country
in the world. Thus success of DOTS in India
would determine the success of TB control
in the world.
The
treatment success rate continues to be high.
86% of the new smear positives registered
in 2nd quarter 2003 were successfully treated
under DOTS. The sputum conversion rate and
cure among the new sputum positives was
89% and 85%, respectively.
DOTS
DOTS
COVERAGE AND TREATMENT SUCCESS RATE SOARS
IN INDIA
In
India, which accounts for 30% of the global
burden of TB, the DOTS programme is undergoing
massive expansion as treatment success rates
double and death rates fall. Government
commitment, community involvement, and partnerships
have all been key factors in the success
of the DOTS programme in India.
A massive expansion of
TB treatment using DOTS is today under way
in India. By the end of 2002, it is planned
that half the country will be covered. Eventually,
it is hoped that the entire population of
over one billion will have access to DOTS.
Up until late 1998, only
2% of the population were covered by DOTS.
By early 1999, the number had soared to
over 120 million and the numbers have been
rising ever since.
The logistics involved
in such rapid large-scale expansion were
considerable. Over 10 000 doctors had to
be trained, 2000 laboratory technicians,
and 100 000 allied health workers. An additional
500 staff were employed. Almost 3000 microscopes
had to be purchased and enough TB drugs
to treat over 400 000 patients. Meanwhile,
hundreds of thousands of technical documents
had to be finalized and printed. Any future
expansion will have to be phased to ensure
that drug supplies, training, supervision,
and monitoring can all be guaranteed. The
stakes are high. India accounts for about
30% of the global burden of TB. An estimated
one in two of the adult population are infected
with the TB bacterium. Every year, two million
people develop active tuberculosis -- more
than in any other country in the world.
And about 450 000 die from it -- more than
the total deaths from AIDS, malaria, and
tropical diseases combined.
Launched in 1993 with a
series of successful small-scale pilot projects,
the DOTS programme has shown continued impressive
success rates. A recent analysis of the
impact of the programme found that 80% of
cases were successfully treated -- twice
as many as in the previous TB programme.
Death rates among infectious patients treated
within the programme were 4%, compared with
a rate over seven times higher in the non-DOTS
programme.
India's DOTS programme
is mainly financed through a US $ 142 million
low-interest loan from the World Bank, with
an increasing proportion of the costs already
being met by the national and state governments.
Treatment is supervised by health workers,
community volunteers, traditional birth
attendants, and community or religious leaders.
Community workers supervise treatment for
patients with limited access to a health
centre. Additional staff are provided to
serve difficult mountainous, tribal, and
urban areas.
In order to maintain the
uninterrupted supply of drugs throughout
the treatment period, each patient is allocated
an individual box at the outset containing
the full course of treatment. This helps
ensure that no patient has to stop treatment
because drugs are not available, even in
the event of a break in the drugs supply
chain.
Ironically, India was one
of the seedbeds for the global DOTS strategy,
but it was many years before the idea took
root there. In the 1950s, the Tuberculosis
Research Centre in Chennai (formerly Madras)
demonstrated that treatment observation
is both necessary and feasible in the community,
using intermittent treatment. In the early
1960s, India demonstrated that most TB patients
did not need to be in hospital. In Madras,
even destitute people living on the streets
in slum areas were successfully treated
with a regular supervised course of TB drugs.
Meanwhile, the National Tuberculosis Institute
in Bangalore demonstrated that, with minimal
training and regular supervision, technicians
working at the periphery could carry out
sputum smear microscopy -- enabling this
to become the primary tool for diagnosis
of TB.
Today, as India establishes
the second largest DOTS programme in the
world (after China), the wheel has turned
full circle. But there is still a long way
to go before DOTS is available country-wide.
1992:
National programme review of tuberculosis
concluded that efforts to control the disease
had not made any significant impact
1993:
Revised National Tuberculosis Control Programme
was begun, applying the principles of DOTS
- which were largely discovered in India
1997:
Government of India obtained a "soft"
loan from the World Bank for US $142 million
to implement the RNTCP in at least one third
of the country and to prepare the rest of
the country for implementation of RNTCP
at a later date; RNTCP in Orissa is supported
by the Danish Government and RNTCP in Andhra
Pradesh is supported by the British Government
1999:
RNTCP expands 7-fold to become the second
largest such programme in the world
2001:
One third of the country covered, more than
5 lakh patients treated
2002:
Plan to cover half the country
The RNTCP has expanded
rapidly in the past year. From a population
coverage of 1.8 crore - less than 2% of
the country - in 1998, by early 2001, the
programme covered more than one third of
the country. This represents one of the
fastest expansions of this strategy anywhere
in the world.
From
1.8 crore population in 1998, the RNTCP
has expanded to reach 35 crore population
in March 2001
Joint
Review of the Tuberculosis Control Programme To assess
the performance of the RNTCP, a joint review
of the tuberculosis control programme was
undertaken in February 2000 by a team of
25 international and national experts. The
team visited more than 100 health facilities,
interviewed more than 1 000 patients and
health workers, and verified the records
of more than 10 000 patients. The review
found that the RNTCP is succeeding and has
already saved more than Rs 1 300 crore (US$
300 million) in economic costs.
Status
& Prospects Conservative
estimates are that nationwide effective
DOTS implementation by 2005 would result
in cumulative savings of more than Rs 108
000 crore (US$ 27 billion) through the year
2020. For an investment of Rs 200 crore
(US$ 50 million) per year, the yield would
be more than Rs 10 000 crore (US$ 2.5 billion)
per year. Full coverage would transfer Rs
700 crore (US$ 160 million) every year to
patients in medical expenses averted. By
early 2001, every day 1 000 patients were
being placed on treatment in the RNTCP,
representing 200 lives saved and 2 000 tuberculosis
infections prevented. More than 500 000
patients had been put on treatment by March
2001, saving nearly 100,000 lives and preventing
more than 1 000 000 TB infections. The challenge
in the years ahead is to maintain the pace
and quality of the programme while achieving
national coverage so that tuberculosis is
no longer a significant public health problem
in India.
A.R.
Rahman to inaugurate TB patients network
Music director and composer A.R. Rahman Saturday
launched 'TB Sangharsh', the first Indian
tuberculosis patients' network, as part of
a nationwide effort to create awareness about
the disease here.
Inaugurating the network, Rahman, who is a
global ambassador for the International Stop
TB Partnership, met patients in west Delhi's
Mongolpuri area. He also interacted with them
about the treatments available and encouraged
them to avail of these. "Every individual
is important for the country and hence it
is better to be disease-free by availing of
the treatment," he said.
Organised by TB Action India, a TB advocacy
NGO, the programme aimes at creating awareness
about the disease among the masses and involving
the patients in the campaign.
The newly formed network will closely work
with both NGOs and patients and advise them
about different kinds of treatment available.
It will also fight the stigma attached to
the disease.
Stop TB Partnership is an initiative of the
World Health Organisation.
Around two million people die of TB every
year and about 30 percent of the world's TB
population lives in India.
City
pilots new TB control plan
JULY 24 MEET
Channa, a science graduate who has completed
a sanitary inspector’s course and
is now totally dedicated to his job as a
Tuberculosis Health Visitor (TBHV). His
target - to cover two lakh residents of
Sahakarnagar and enlist private practitioners
to treat TB patients.
“I travel from 8 am till 8 pm informing
community members and sensitising doctors
to get involved in the Revised National
Tuberculosis Control Programme,” he
says about his job — one among 14
other health visitors appointed by the Pune
Municipal Corporation (PMC) as part of a
pilot project of the Union government’s
TB division and WHO.
Pune is one of the 14 cities in the country
that will involve private practitioners
in the revised TB control programme, says
Dr Dilip Jagtap, Secretary of the PMC TB
Control Society.
The PMC’s health visitors were chosen
for the six TB units of Gadikhana, Bhawani
Peth, Sahakarnagar, Hadapsar, Gandhinagar
and Kothrud.
So far, the results are encouraging. At
least 377 private practitioners are involved
in the programme. Of these, 177 work on
the WHO recommended Directly Observed Treatment,
Short-Course strategy or DOTS, which consists
of sustained government commitment, effective
laboratory-based diagnosis, standard treatment
given under direct observation, secure drug
supply and systematic monitoring and evaluation.
While the pilot project commenced a few
months ago, Jagtap says the PMC TB control
society has been encouraging private practitioners
to join the programme over the last 5 years.
Already two medical colleges and 25 NGO’s
are involved. Henceforth, Central Government
Health Scheme (CGHS) and Employees State
Insurance Scheme (ESIS) will be involved
with the national TB control programme.
Every year, approximately 2 million people
in India develop tuberculosis, accounting
for one fourth of the world’s new
TB cases. In Maharashtra, Mumbai has the
highest number of cases due to migrant population
and overcrowding. Due to the involvement
of private practitioners and other players,
there has been an increase in the number
of patients diagnosed with tuberculosis.
In Pune, the PMC TB Control Society diagnosed
3,876 cases in 2004. According to WHO norms,
at least 160 cases of TB should be diagnosed
for one lakh population.
“We are by and large meeting those
norms and due to increasing private participation,
the number of patients diagnosed with TB
has increased in the last two quarters -
over 2,350 patients have been diagnosed
from January this year,’’ says
Jagtap. The next step is sensitising CGHS
and ESIS doctors, he adds.
Public
private mix projects for TB control
Chandigarh,
the capital city of the North Indian States
of Punjab and Haryana is one of the fourteen
cities in the country implementing pilot
Public-Private-Mix (PPM) projects initiated
by Revised National Tuberculosis Control
Programme (RNTCP). These PPM projects launched
in second half of the year 2003 are located
mostly in state capitals or larger cities.
Dr.
Parmod Sridhar, State TB Officer, is enthused
by the promising results of PPM project
in Chandigarh. Talking to TBNI he said,
“Our programme caters to one million
people. At any given time, we expect to
have at least 900 patients on DOTS. In April
2005, 914 patients were being provided DOTS
in Chandigarh and the contribution of PPM
project was an impressive 314 patients.”
“When
we began to sensitize private doctors we
realized that it was not so easy to bring
together family physicians, specialists
and super-specialists on one platform for
meetings or workshops,” says Sridhar,
reminiscing the early days of PPM project
in Chandigarh.
“PPM
methodology in India provides a number of
options or schemes for a range of situations.
We in Chandigarh opted for schemes I and
II which involve referring chest symptomatic
patients (persons with cough for three weeks
or more) to microscopy centers for sputum
examination and working as DOTS providers
respectively”, Sridhar explains.
“We
were able to associate ninety-five private
doctors under the first scheme. Some of
them were physicians from other systems
of medicine such as Ayurveda or Unani. The
office bearers of local branch of Indian
Medical Association (IMA), representing
allopathic doctors, were initially reluctant
to work with them”, he remembers.
“We
explained to them that the thirteen slum
colonies of Chandigarh were a priority area
for our project. The number of allopathic
doctors doing practice in such colonies
was very low. Therefore, the people in these
localities depended on physicians from other
systems of medicine for health care. These
physicians were an appropriate mean of reaching
out to chest symptomatic patients,”
says Sridhar. “It took a couple of
meetings and back-up from IMA national headquarters
before the local branch members agreed to
work with them”, he notes with a sense
of relief.
Fifty-five
physicians (all of them practicing modern
system of medicie) were selected as DOTS
providers under the Scheme II. They included
fifteen working in charitable clinics run
by voluntary or community based organizations.
“Chandigarh
is considered to be one of best planned
cities of the country but even it has thirteen
big slum colonies. We divided these in four
zones. Our aim was that no patient had to
travel more than two kilometers for sputum
examination and one kilometer for a DOTS
center. We have been largely successful
on this front”, he said while providing
an insight in to the planning process.
“We
approached the local Municipal Corporation
(MC) for financial help to appoint 13 Community
Health Volunteers (CHV), so as to augment
our presence in these colonies. We were
lucky to get funds from MC under the Union
Government’s Swaran Jayanti Shehri
Rojgar Yojna (Golden Jubilee Urban Employment
Plan) and now we have one CHV for approximately
30,000 to 40,000 people. They are paid Indian
Rupees 1000 (US$ 24 approximately) every
month. They are our watchdogs inside these
communities. They help spread the messages
of programme, identify newly arrived outsiders,
locate addresses of the patients who leave
the city and treatment midway and contact
defaulting patients. No surprise the defaulter
rate in Chandigarh has fallen to 2.5 percent”,
he declared with a sense of satisfaction.
Dr.
Sridhar has very ambitious plans for PPM
project in Chandigarh, “At present
one third of our patients on DOTS come from
private sector, we want to gradually increase
it to fifty percent and finally reach a
level when two third of patients will come
from non public health sources”, he
asserts.
Revised
National TB Control Programme (RNTCP) has
accomplished
100% coverage of the country under DOTS
Union Health Minister Dr. A. Ramadoss, on
the occasion of World TB Day announced that
after accomplishing 100% coverage of the
country under DOTS during March 2006, the
Revised National TB Control Programme now
aims to widen the scope for providing standardized,
good quality treatment and diagnostic services
to all TB patients in a patient friendly
environment, in which ever health care facility
they seek treatment from.
India
to Implement National Action Plan against
TB-HIV
India under the Revised National TB Control
Programme (RNTCP) aims at widening the scope
for providing standardized, good quality
treatment and diagnostic services to all
tuberculosis patients. It is known that
about 50 - 60 % of HIV-positive people are
more prone to contracting tuberculosis.
Hence the Union Health and Family Welfare
Minister Anbumani Ramadoss plan to tackle
this issue and multi-drug resistant cases.
He said this after releasing the RNTCP Status
Report for India, 2006. He said that various
measures are taken to tackle TB-HIV.
In the first phase, the
six high-HIV prevalent States of Maharashtra,
Tamil Nadu, Andhra Pradesh, Karnataka, Manipur
and Nagaland were identified for implementation.
The services are being provided for HIV-infected
TB patients by involving Voluntary Counselling
and Testing Centres and the RNTCP Designated
Microscopy Centres and non-governmental
organizations. The Ministry is conducting
community-based surveys among new and re-treatment
cases in Gujarat and Maharashtra to estimate
the number of people who have become resistant
for drugs.
Other states will also
be strictly monitored to help the Government
by observing the trends in resistance. According
to the statistics drug resistance in new
cases is less than 3% and in old cases it
is about 10 %. Reports and data say that
about 1.8 million people in India develop
tuberculosis every year and nearly 3,70,000
die from it. The disease has devastating
social costs. About 3 lakh children are
forced to leave school because their parents
have TB, and more than 1 lakh women with
TB are rejected by their families every
year.
The Stop TB Strategy
Vision
A WORLD FREE OF TB
Goal
To dramatically reduce the global burden of TB by 2015 in line with the Millennium Development Goals and the Stop TB Partnership targets.
Objectives
Achieve universal access to high-quality diagnosis and patient-centred treatment
Reduce the human suffering and socioeconomic burden associated with TB
Protect poor and vulnerable populations from TB, TB/HIV and multidrug-resistant TB
Support development of new tools and enable their timely and effective use
Targets
MDG 6, Target 8: ...halted by 2015 and begun to reverse the incidence.....
Targets linked to the MDGs and endorsed by the Stop TB Partnership:
by 2005: detect at least 70% of new sputum smear-positive TB cases and cure at least 85% of these cases
by 2015: reduce prevalence of and death due to TB by 50% relative to 1990
by 2050: eliminate TB as a public health problem (<1 case per million population)
1. Pursue high-quality DOTS expansion and enhancement
Political commitment with increased and sustained financing
Case detection through quality-assured bacteriology
Standardized treatment with supervision and patient support
An effective drug supply and management system
Monitoring and evaluation system, and impact measurement
2. Address TB/HIV, MDR-TB and other challenges
Implement collaborative TB/HIV activities
Prevent and control multidrug-resistant TB
Address prisoners, refugees and other high-risk groups and special situations
3. Contribute to health system strengthening
Actively participate in efforts to improve system-wide policy, human resources, financing, management, service delivery, and information systems
Share innovations that strengthen systems, including the Practical Approach to Lung Health (PAL)
Adapt innovations from other fields
4. Engage all care providers
Public-Public, and Public-Private Mix (PPM) approaches
International Standards for Tuberculosis Care (ISTC)
5. Empower people with TB, and communities
Advocacy, communication and social mobilization
Community participation in TB care
Patients' Charter for Tuberculosis Care
6. Enable and promote research
Programme-based operational research
Research to develop new diagnostics, drugs and vaccines
