TUBERCULOSIS PROGRAMME REVIEW INDIA, SEPTEMBER 1992
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TUBERCULOSIS PROGRAMME REVIEW
INDIA, SEPTEMBER 1992
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TUBERCULOSIS PROGRAMME REVIEW
INDIA, SEPTEMBER 1992
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TABLE OF CONTENTS
PAGE NO
EXECUTIVE SUMMARY AND RECOMMENDATIONS
1.
2.
INTRODUCTION
3.
LIST OF ABBREVIATIONS
TUBERCULOSIS IN INDIA
' 4.
ORGANIZATION OF THE PROGRAMME
5.
6. , CASE FINDING AND DIAGNOSIS
7. TREATMENT
8.
PROGRAMME MANAGEMENT
8.1 CASE NOTIFICATION
8.2 SUPPLIES AND TRANSPORT
8.3 SUPERVISION, MONITORING AND EVALUATION
8.4 EDUCATION AND TRAINING
9. PRIVATE SECTOR
10. RESEARCH
11. SITUATION ANALYSIS
12. RECOMMENDATIONS
3
7
8
9
14
19
22
26
26
27
28
30
31
32
33
36
ANNEXES
1.
2.
3.1
3.2
4.1
4.2
5.1
5.2
6.1
6.2
LIST OF PARTICIPANTS
INSTITUTIONS VISITED AND PERSONS INTERVIEWED
BACKGROUND INFORMATION
MAP OF INDIA
PRESENT TREATMENT PRACTICES
GUIDELINES FOR TREATMENT ORGANIZATION
COORDINATION WITH OTHER PROGRAMMES
VOLUNTARY HEALTH ORGANIZATIONS
EPIDEMIOLOGY REFERENCES
GENERAL REFERENCES
37
38
42
49
51
53
56
58
59
60
Community Health Cell
Library and Documentation Unit
367, "Srinivasa Nilaya"
Jakkasandra 1st Main,
1st Block, Koramangala,
BANGALORE-560 034.
Phone : 5531518
V
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3
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I
TUBERCULOSIS PROGRAMME REVIEW - INDIA, 1992
EXECUTIVE SUMMARY
•«
The Government of India, recognizing the magnitude of the problem of
tuberculosis, the limited progress achieved by previous control activities
and the expected Increase in incidence as a consequence of the HIV epidemic
has decided to give priority to tuberculosis control. In support of this
decision the Government requested WHO to carry out a joint programme review
together with other Interested parties. A Steering Group was designated to
coordinate the evaluation of the programme, as a first step to formulating a
project for possible external assistance.
The review of the national tuberculosis programme (NTP) of India was
carried out by a team representing the Government of India (GOI), the World
Health Organization and the Swedish International Development Agency (SIDA).
The purpose of the review was to evaluate present policies and practices,
analyze their adequacy to reduce the tuberculosis problem and recommend
organizational, technical and administrative measures to improve the
programme.
The review team analyzed the available documenta including
epidemiological data and reports of previous evaluations of the programme,
discussed with officers of major institutions involved in disease control and
in training, and made field visits in three States (Gujarat, Uttar Pradesh
and Tamil Nadu) to assess the programme at the State, District and peripheral
levels.
The burden of tuberculosis in India is staggering by any measure. More
thaN half of the adult population is infected. About 1.5 million cases are
notified every year and there are probably well over 500 000 tuberculosis
deaths annually. Recent trends show that the programme is not having a
measurable impact on transmission and appears to function far below its
potential.
The Government of India formulated the NTP in 1962. The major objectives
were to prevent tuberculosis through BCG vaccination; to diagnose
tuberculosis cases among symptomatica and provide efficient treatment, giving
priority to sputum positive patients; and to implement these activities as an
integral part of general health services. The District was the basic unit for
the NTP organization.
At present, organization of the general health system has been extended
■ primary •health services,
’
The tuberculosis
to reach the community level- with
programme is integrated into the general health services, and treatment
services are provided at the levels where medical staff is available.
However, the population growth and the proliferation of public health
services has made many Districts unwieldy for supervision by the tuberculosis
team which is based in a single District Tuberculosis Center. Further,
monitoring and training are mainly under the responsibility of the National
Tuberculosis Institute (NTI), the State TB officers playing only a minor role
in these Important areas.
Human and financial resources are provided by GOI and the States to cover
most of the needs of the programme and current policy is to provide free
diagnosis and treatment. Currently available data do not allow analysis of
the adequacy or efficiency with which these resources are applied, but
preliminary indications and overall TB programme performance point to the
need, for substantial Improvements. If the programme is to operate as Intended
and begin to make a significant impact on the disease, increased funding will
be necessary, emphasizing the need for Improvements in programme
effectiveness and efficiency.
4
The presMkt manaftmtnt Structure ac national level requires strengthening
to aifuea leadership in redefining policies, effectively assisting States and
supervising programme implementation, retraining staff involved in TB
activities, administering funds, and procuring supplies. The States, which
provide health services, need also to assume their responsibility in TB
programme management, and will require reorganization and training of the
public and non government health institutions involved in TB control.
There is little coordination between hospitals and primary health
institutions in rural areas, and between the different services providing
tuberculosis care in most urban areas, to ensure the management of
tuberculosis patients until cure.
Improvements in the methods and management of case finding must take
place. In spite of the recognized priority of bacteriological diagnosis and
cure of sputum positive cases to reduce the problem of tuberculosis, a large
proportion of human and financial resources is currently used to treat cases
diagnosed only on clinical and radiological evidence. This practice is common
both to the NTP and to private practitioners and is reflected in medical
college curricula. Bacteriology is not sufficiently used to confirm medical
diagnosis and criteria for initiating treatment in sputum negative cases are
not well defined. As a result of not identifying correctly smear-positive and
smear-negative cases, and newly diagnosed and previously treated patients,
some patients may be treated with inadequate regimens. Sputum microscopy
examinations are carried out with insufficient standards and microscopy
laboratories are Inadequately equipped. A TB laboratory network assuring
equipment, training and quality control is not in place.
&
Rationalization of treatment is required. There are currently too many
alternative treatment regimens and the conventional regimens are of
unnecessary long duration and low effectiveness. Short course chemotherapy
regimens of higher cost-effectlveness are slowly being implemented but
insufficient priority has been given to ensuring effective treatment of
infectious patients, particularly during the initial intensive phase of
chemo therapy.
The present system of recording and monitoring patient identification and
progress during treatment to ensure health service concentration on acl ‘ eving
cure of infectious cases is seriously deficient. The present system does not
allow the systematic evaluation of the results of treatment at health
facility or block level. Neither does the registration system permit the use
of cohort analysis of patients to assess cure rate as the main indicator of
prorraroe efficacy.
Drvg supplici are occasionally interrupted by lack of timely funding and
of buffer stocks. Additionally, the quality of the drugs supplied is not
controlled. The extensive network of multipurpose health workers (MPHW) has
not been sufficiently utilized at the community level to prevent defaulting
and achieve treatment completion.
The present training system relies mainly on the National Tuberculosis
Institute (NTI) courses. The state-level demonstration and training centres
do not function. District Tuberculosis Centres (DTCs) are not adequately
prepared to provide in-service training for dissemination of policy and
standards. It does not make adequate use of training Institutions and NGOs at
the State level to transmit current policies and procedures. The curricula
at medical colleges do not stress the basic principles of TB control and
there is no systematic continuing education for medical practitioners.
A
5
In spite of extensive national experience in both operational and basic
T1 rtissrch, alternative methods to correct the extremely low proportion of
cases diagnosed with bacteriological confirmation and of patients completing
the prescribed treatment and cured have seldom been implemented. The
findings of previous programme evaluations have not always been applied to
improve existing programme procedures, nor has adequate use of the results of
research and programme evaluation been made.
Nonetheless, the basic strengths of the India TB programme are
considerable. The objectives on which the programme was established thirty
years ago - integration, decentralization, free services, priority to
treatment of infectious cases - are still valid today. They provide a sound
basis for revitalization of the national TB strategy. In addition, the
tuberculosis control programme can relatively easily build on its strengths:
a well defined structure which provides services within general health care
in an integrated manner; a basic managerial unit at District level with
Central and State Governments providing support for diagnosis and treatment;
experienced training and research institutions; and, a general health care
system extended to the community through multipurpose health workers. An
updated and strengthened programme can expect to reduce the magnitude of the
problem by about half in each 10-15 years with the conseqi^ent savings in
lives, human suffering and more effective use of financial resources. This
will require a political commitment, initial investment and strong
leadership, plus the rapid development of an efficient national model to
serve as training ground and provide operational experience to programme
managers at all levels.
RECOMMENDATIONS
1.
The structure of the National Tuberculosis Programme should be
strengthened by 1) establishing an apex policy making authority and an
executive task force with managerial functions to implement programme
reorganization, and 2) upgrading the central tuberculosis control unit in
the Directorate to provide strong leadership and enhance the efficiency
and effectiveness of the National Tuberculosis Programme.
2.
The quality of patient diagnosis should be Improved by 1) using three
smear examinations to detect infectious cases among symptom*’ Les before
deciding on patient treatment, 2) ensuring the quality of microscopy with
adequate equipment, training and quality control, and
3) establishing criteria for diagnosis by radiological and clinical
methods.
3.
National and state tuberculosis programme resources should be directed to
ensuring cure of tuberculosis patients, giving priority to infectious
cases of tuberculosis by 1) adopting short-course chemotherapy, 2)
establishing criteria for treatment completion, cure and discharge from
medical care, and 3) ensuring an uninterrupted supply of drugs of good
quality.
4.
The current NTP system of registration and notification should be revised
to emphasize the cohort analysis of treatment results (completion and
cure, transfers, defaulters, died, treatment failures) as the pain
indicator of programme effectiveness •
5.
Policies should be developed to ensure decentralization of treatment
services closer to the community level to enhance access to care and
patient compliance to recommended therapies.
6.
Pilot projects should be implemented at block level to test the
feasibility and results of different technical and organizational
6
strategies to be adopted by the tuberculosis progrb—r -- l.e., to test
the capacity to implement recomMndations 2-5 above.
7.
A medical officer or treatment organizer and a laboratory supervisor,
with the necessary transport, should be added to the existing
administrative structure at the sub-district level (about 500,000
population) to strengthen tuberculosis programme management and to
facilitate decentralization of supervlsicn.
8.
Training materials must be developed to reflect the proposed changes in
programme policies and procedures. The current training infrastructure
will need to broaden the scope of its training capabilities by utilizing
state training facilities, medical colleges, public health institutes and
tuberculosis-oriented voluntary agencies to augment training efforts.
International and national training opportunities should be made
available for the different levels of tuberculosis programme staff.
9.
Operational research must be carried out as an integral part of the
revised tuberculosis programme to evaluate programme performance, improve
delivery of services, problem solving and obtain baseline epidemiological
information to measure reduction in the risk of infection.
7
INDIA - TUBERCULOSIS PROGRAMME REVIEW 1992
2
INTRODUCTION.
A review of the national tuberculosis programme was carried out from
9/1/92 to 9/17/92 as a collaborative effert of the Government of India (GOI),
the World Health Organization (WHO) and the Swedish International Development
Agency (SIDA). The purpose of the review was to evaluate present policies
and practices, analyze their adequacy to reduce the tuberculosis problem and
recommend organizational, technical, and administrative measures to improve
the programme. The assessment included:
1.
2.
3.
4.
An overall description of the current programme achievements and
problems,
An analysis of the tuberculosis burden, the programme resources and
the programme structure,
Specific discussion of the leading Issues facing the programme and
their underlying causes, and
Recommendations for the next steps to improve the programme.
At the central level the team reviewed information relating to the
magnitude of the tuberculosis problem in the country and epidemiological
trends t programme structure, policies, technical norms and procedures
relating to tuberculosis diagnosis and treatment, drug supply and logistics,
supervision, monitoring and evaluation, education and training, coordination
with other programmes and research. Meetings were held with the Ministry of
Health, major referral facilities in New Delhi and voluntary organizations.
Following the review at the central level, the review participants
divided into three teams to assess tuberculosis control activities at the
State and District levels through facility visits and interviews with
responsible staff in three selected States (Tamil Nadu, Gujarat, and Uttar
Pradesh).
2 *_* Then the
_*
teamsi reconvened
reconvened in
in Delhi
Delhi for
for discussion
discussion of
of the
the review
review
findings, conclusions and development of principal recommendations for
M
“ 7 of . India.
A draft summary of the conclusions
submission
to the Government
and main recommendations was presented to the Secretary of Health at the end
of the review.
A list of participants is attached in Annex 1, and a list of persons
contacted and institutions visited as part of the review is in Annex 2.
This document summarizes the findings of the review. Background
information on India can be found in Annex 3.1.
8
3. LIST OF ABBREVIATIONS
ADGHS
BCG
CHC
DGHS
DHO
DOT
DTC
DTO
DTP
EPI
GH
GNP
GOI
GP
H
ICMR
IMA
IMR
MBTC
MG
MCH
MO
MOH/FW
MPW
NGO
NRR
-NTI
NTP
PEC
PHI '
PPD
R
RC
RI
RS
S
SCO
SIDA
STO
STTDC
T
TAI
TRC
VHAI
XC
ASSISTANT DIRECTOR GENERAL OF HEALTH SERVICES
BACILLI CALMETTE & GUERIN
COMMUNITY HEALTH CENTRE
DIRECTOR GENERAL OF HEALTH SERVICES
DISTRICT HEALTH (MEDICAL) OFFICER
DIRECTLY OBSERVED TREATMENT
DISTRICT TUBERCULOSIS PROGRAMME
DISTRICT TUBERCULOSIS OFFICER
DISTRICT TUBERCULOSIS PROGRAMME
EXPANDED PROGRAMME OF IMMUNIZATION
GENERAL HOSPITAL
GROSS NATIONAL PRODUCT
GOVERNMENT OF INDIA
GENERAL PRACTITIONER
ISONIAZID
INDIAN COUNCIL OF MEDICAL RESEARCH
INDIAN MEDICAL ASSOCIATION
INFANT MORTALITY RATE
MASTER BOOK OF TREATMENT CARDS
MYCROSCOPY CENTRE
MATERNAL AND CHILD HEALTH
MEDICAL OFFICER
MINISTRY OF HEALTH AND FAMILY WELFARE
MULTI-PURPOSE HEALTH WORKER
NON-GOVERNMENTAL ORGANIZATION
NET REPRODUCTIVE RATE
___
NATIONAL TUBERCULOSIS INSTITUTE
NATIONAL TUBERCULOSIS PROGRAMME
PRIMARY HEALTH CENTRE
PERIPHERAL HEALTH INSTITUTIONS
PURIFIED PROTEIN DERIVATIVE
RIFAMPICIN
REFERAL CENTRE
RISK OF INFECTION
RUPEES
STREPTOMYCIN
___
SHORT COURSE CHEMOTHERAPY
__
SWEDISH INTERNATIONAL DEVELOPMENT AGENCY
STATE TUBERCULOSIS OFFICER
STATE TUBERCULOSIS TRAINING AND DEMONSTRATION
CENTRE
THIOACETAZONE
TUBERCULOSIS ASSOCIATION OF INDIA
TUBERCULOSIS RESEARCH CENTRE
VOLUNTARY HEALTH ASSOCIATION OF INDIA
X-RAY CENTRE
'4
9
4, TUPnCVLOtll IF INDIA
Prevalence of infection- a number of studies over the past 30 years, mainly
in rural amithern India, have shown the prevalence of Infection among
children 0-9 years old to be between 3.IX and 11.2X (Table 1). In the early
1960s, more than SOX of the population 20 years and older was Infected with
M- tuberculosis and most infections occurred before 15 years of age. By the
late 1960s there was no evidence of change in this pattern. Since that time,
there is no clear evidence of substantial changes in prevalence of infection
among children beyond that which might have been expected from secular
trends.
Table 1- India: Prevalence of tuberculosis Infection among un-vaccinated
children 0 to 9 years old and estimated annual Risk of Infection (RI)
RI
Year
Location
Source
4.9X
1.0X
1961
Tumkur
NTI
9.6X
2. OX
1969
Tiruvallore
TRC
10. IX
2. IX
1983
Bangalore
NTI
10.4X
2.2X
1984
Dharnapuri
NTI
3.IX
0.6X
1985
Bangalore
NTI
9. OX
1.9X
1989
Kadambatmur
TRC
11.2X
2.3X
1989
Thiruvelangadu
TRC
6.7X
1.4X
1989
North Arcot
TRC
Prevalence of
infection
Annual risk of infection- The intensity of disease transmission in the
community is best reflected by the annual Risk of Infection (RI) which
represents the probability of a previously uninfected individual becoming
infected with tuberculosis during a one year period.
Ria calculated from prevalence studies presented 'in Table 1 range from
0.61 to 2^31^ These data are difficult to Interpret because methods vary
among surveys but they clearly indicate vide variation within limited
geographical areas and provide no clear evidence of a substantial decrease of
the risk of infection over the last 30 years. This stagnant situation is
substantiated by two recently published studies conducted in rural areas of
Southern India. One showed that the RI decreased from 1.0X in 1961 to 0.61X
in 1985, equivalent to an average decline of 3.2X per year. The other study
showed no decrease in the risk of Infection between 1969 and 1984 (RI of 1.7X
in both years). These results would be consistent with a poorly functioning
programme which would be creating chronic cases of tuberculosis and drug
resistance .*
Because most adults were Infected in their youth, a small decrease of the
RI would not have any rapid impact on the prevalence of Infection in the
adult population. It is safe to estimate that at least 50X of the population
above the age of 20 years Is Infected and will remain at risk of disease and
death from tuberculosis for their lifetime. A conservative estimate is that, .
currently, the RI for India is still between IX and 2X.
Disease prevalence- The Sample Survey of tuberculosis conducted between
1955-58 remains the major source of Information used by the NTP to anticipate
10
the tuberculosis situation in the country. The survey showed wide variations
in prevalence of disease among persons aged 5 years or more (sputum-positive
tuberculosis by smear or culture), ranging from a low of 229/100,000 to a
high of 813/100,000. The overall prevalence was 398/100,000.
In 1960-61 and in 1972-73 surveys conducted by NTI showed the prevalence
of radiological disease to be 1900 and 1100 per 100,000 respectively. In
1990, ,in an area near Madras, the rate was estimated to be 1700/100,000. In
the first of these studies, the prevalence of sputum-positive tuberculosis
was 410/100,000 and in others studies conducted by NTI between 1961 and 1968
in the Bangalore area the prevalence of bacteriologically confirmed
tuberculosis (smear or culture-positive) ranged from 337 to 406/100,000 over
the age of 5 years. About half of these cases (45X to 52X) were smear
positive. In a number of surveys and studies since that time, there is no
evidence of a significant decrease in TB during the last three decades and
there remains a very wide range of prevalence of TB in India. In the 1972-73
follow up of the 1960-61 study, the prevalence of bacteriologically confirmed
disease was 440/100,000. Two studies conducted in 1989 and 1990 in two areas
near Madras in the population above the age of 15 years found prevalence of
bacteriologically confirmed disease of 1090 and of 430/100,000 (58X and 69X
of confirmed cases were smear-positive).
The only clear exception to this stagnant situation Is recent data from
- the Tuberculosis Prevention Trial1, in which a 350 000 population of South
India is being followed prospectively. This study Indicates a decrease in
prevalence and incidence of both radlologlcally active and sputum-positive
tuberculosis between 1968 and 1985. Most of the decrease, however, occurred
during the first few years of the study. Data from 1978 to 1985 show
stagnation with a prevalence about 1700/100 000 above the age of 10 years old
(by X-ray or culture) and an incidence of about 450/100 000 over the age of
10 years (X-ray or culture). During the same period, SOX of all cases had
bacteriologically confirmed (culture-positive) tuberculosis.
Among the many factors influencing prevalence of disease, the
effectiveness of treatment is important. Poor treatment completion
significantly increases the prevalence of disease. A recent retrospective
cohort study conducted under programme conditions by the Tuberculosis
Research Centre (TRC), Madras, illustrates the potential impact of poet*
treatment completion. It showed that among patients on short course
chemotherapy who collected less than 50X, SOX to 79X and SOX or more of their
drugs, 44X, 37X and 21X respectively were still sputum smear-positive after
the end of treatment2.
Low effectiveness of the treatment programs explains much of the
stagnation in disease trends over the last three decades. Further, with the
current treatment completion rate it is probable that chronic and partially
treated patients represent a large proportion of patients diagnosed by the
programme.
Current tuberculosis rates. Age specific incidence rates (NTI, 1974)
estimates suggest that about 870 000 new smear-positive cases of tuberculosis
may have occurred in 1992. This number is very similar to the 850 000
estimate obtained on the basis of Incidence data from the Tuberculosis
Prevention Trial3. If the current average annual risk of infection is 1.7X,
1
S.P. Tripathy, personal comaunicatlon, 1992
2
TRC Annual Report, 1990
3
S.P. Tripathy, personal communication, 1992
. J
11
1.6 million new cases (all forms) and 714 000 new smear-positive cases of
tuberculosis may occur annually. About a third of the total tuberculosis
burden of India is borne by the urban conglomerations consisting mainly of
towns, cities, and their suburbs.
Notlficatlong. Based on the average case notification from districts with
existing tuberculosis programmes (with about 83X of the population of the
country), NTI estimated more than 1.5 million newly registered cases of
pulmonary tuberculosis in 1991. 21X of them were smear-positive. The trend in
notification, presented in Figure 1, reflects the increase in the number of
districts integrated in the tuberculosis programme from 320 in 1980 to 387 in
1991,- and also an Increased proportion of cases not confirmed by smear
examination. The proportion of smear-positive cases has decreased from 25X in
1980 to about 20X in the late eighties. Relapses, failures and partially
treated patients are often inapproplately included in these notifications.
Figure 1. India: Notifications of cases
of tuberculosis, 1980-1991
Thousands
1500
All pulmonary
1200
900
600
300
Q ______ I_________ I_______ 1_______ I_______ I_______ I_______ ________ I_______ I-------------1-------------1
1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991
Year
Extra-pulmonary caaaa are not reported
Sourcoi NTI. 1092
12
Age and sex distribution.- The majority of tuberculosis cases in India occur
below the age of 45 years, with about 75X of the diagnosed cases between 15
and 44 years old. Age-specific estimates of incidence from 1974 applied to
the 1992 population, would imply that about 58X of all cases today occur
between 15 and 44 years old. Two thirds of the cases are estimated to occur
among males but tuberculosis takes a proportionally much larger toll on young
females than among young males. More than SOX of female cases occur before
age 34.
Mortality. Total mortality due to TB is uncertain but by any estimate poses
a huge economic burden for India. Tuberculosis mortality is estimated by NTI
to have been 69 to 95/100 000 in 1961-68 and 41/100 000 in 1977-81. or over
350 000 tuberculosis deaths annually (Table 2). Data from the Survey of
Cause of Deaths yield a more recent parameter by which to estimate current
mortality, resulting in 400 000 deaths, about 75 000 deaths in the 15-24 age
group, 95 000 in the 25-34 age group and about 160 000 deaths in the 35-44
age group. Using the 1955 Sample Survey estimates of Incidence, if all cases
were diagnosed and at the present treatment completion rate of 30X, there
would bo about 657 000 annual deaths of tuberculosis. A large proportion of
these deaths occur among women and it has been estimated that maternal
mortality and tuberculosis claim approximately the same number of lives, For
the decade of the 1990's, any of these estimates implyes a staggering
cumulative burden for the disease.
Table 2.
Indic Estimates of probable tuberculosis mortality
Source
& year
Estimated
mortality
per 100 000
Annual deaths
Approximate (1)
cumulative deaths
1990-2000
NTI
77-81
41.0
346 000
3 460 000
Causes of deaths survey
92
50.0
422 000
4 220 000
Sample Survey Incidence estimates (2)
55-58
77.8
657 000
6 570 000
"Styblo •odal" of incidence with 1.5X RI (2)
320
92
50.1
432 000
4 22
1 000
(1)
(2)
Mortality rates from surveys applied to 1992 population structure and
cumulative burden not adjusted for age structure within the decade.
Assuming no improvement from the current treatment completion rate of
30X and assuming 100X coverage of new cases.
Using the number of cases of tuberculosis currently notified by the NTP»
the reported completion rate (30X), a case fatality of 10X among patients who
complete treatment, 48X among smear positive-patients who did not complete
treatment and 24X among smear-negative patients, it can be estimated that
about 345 000 tuberculosis patients today diagnosed in the programme die.
Almost all of these deaths are preventable. Increasing the treatment
completion rate to only 85X would prevent close to 200 000 deaths annually,
57X decrease in mortality.
13
Table 3. India: Number of Tuberculosis deaths which could be expected among
cases officially reported in 1991 at different rates of treatment completion
and potential reduction in mortality.
Completion
rate
30X (current)
40X
70X
85X
Expected deaths among
Smear
positive
Total
cases
Reduction in mortality
(all cases)
Lives
Percentage
saved
reduction
121 000
109 000
71 000
52 000
345 000
309 000
202 000
148 000
Base line
36 000
143 000
197 000
10X
41X
57X
* Pulmonary. As extra-pulmonary cases are not reported, they are not
included in this calculation
Cumulative mortality during the decade to the year 2000 will probably
exceed 3.5 million deaths, an enormous burden for society. A large share of
these premature deaths can be avoided with a well-functioning programme.
Given the ages at which deaths from tuberculosis are now occurring and the
low costs for tuberculosis programme inputs in India, it is probable that the
discounted cost per healthy year of life gained as a result of a well
functioning tuberculosis control programme will be well under US $10, making
tuberculosis control one of the highest priority Interventions for the State
and central governments.
<1
AIDS and tuberculosis. HIV began to spread in India only in the latter part
of the 1980s and there is no evidence yet that HIV infections are having an
impact on the tuberculosis situation. Only recently HIV testing has become
more common in a few research and academic institutions. A survey conducted
among all newly diagnosed smear-positive tuberculosis patients in 1990 in
Madras found 15 confirmed positive HIV cases among 2165 patients tested
(0.7X). In Vellore, there were 16 confirmed HIV positives among 906 patients
newly diagnosed with pulmonary tuberculosis (1.8X). In 1992, 12 of 183
(6.3X) tuberculosis patients admitted to a hospital in Bombay were HIVinfected. In a follow-up study of 220 HIV infected Individuals conducted in
Madras, 115 (52X) had radiological evidence of tuberculosis and ^4 (15X) were
culture positive. Other studies of HIV-prevalence in the general adult
population have revealed prevalence varying between O'IX in Calcutta to IX in
Bombay. The AIDS programme estimates that currently there are 750 000
persons infected with HIV in the country and that there will be 5 million in
the year 2000. Assuming half of these people are also infected with
tuberculosis, and that the breakdown rate from tuberculosis infection to
disease among dually infected individuals is 10X per year, more than 35 000
HIV-related tuberculosis cases will occur in 1992. There may be as many as
250 000 HIV-related tuberculosis cases annually at the end of the decade.
Virtually all of these cases will be in addition to the expected incidence.
As important as these cases will be, they will continue to represent only a
fraction of the cumulative cases of tuberculosis during the decade.
Tuberculosis drug regjgtance« Only a few laboratories can conduct drug
sensitivity testing in India. Although data on drug resistance is scarce and
resistance is not systematically monitored, available Information (Table 4)
is cause for concern. The very high rate of secondary resistance to both
rifampicin and Isoniazid is particularly serious, with long term implications
as these patients will transmit a virtually incurable form of disease within
the community.
14
Table 4: India: Primary and Acquired Drug Resistance in selected‘areas.
Type of patient
and sample size
S
Resistance to
H
R
HR
SHR
Failure
16.0
33.3
61.5
6.0
9.0
35.0 62.0
11.7 52.7
13.5
17.1
5.4
5.4
8.1
11.7
7.3 12.6
11.0 19.1
18.5
1.6
3.2
0.8
2.0
0.6
0.8
1.2
50.7
78.8
30.0 65.0
Previously Treated
Madras (2)
37
Raichur (2)
111
Nev cases by history
Madras (2)
241
244
Raichur (2)
324
Delhi (1)
81
354
560
(1) :
(2) :
Delhi Centre (1)
Delhi Suburbs (1)
North Arcot (2)
Ind. J. Tub. Vol.39 No.2 pp 121-124
TRC Annual Report and M. Datta, personal communication
Conclusions *
The burden of tuberculosis in India is staggering by any measure. About
1.5 million cases are notified every year, more than half of the adult
population is infected, and there are at least 300 000 tuberculosis deaths
annually. Social and economic consequences of tuberculosis for individuals
and for the society are enormous in human suffering, economic loss, and
decreased productivity. Recent trends are discouraging, indicating a
programme which does not have any measurable impact and which appears to
function far below its potential. While further study and improved analysis
are needed to rigorously document the epidemiological situation, it will not
change the broad conclusion that tuberculosis is one of India's most serious
and still neglected health problems.
5, ORGANIZATION QF THE PROCRAMMB
1. National Level- The Ministry of Health and Family Welfare (MOH/FW) is
divided into an administrative arm headed by the Secretary of Health and a
technical arm headed by the Director General of Health Services (DGHS). The
Secretary of Health is assisted by Additional Secretaries and the DGHS by
Additional DGHSs and several Deputy DGHSs. <One of these Deputy DGHS
supervises the NTP as well as several other programmes, The responsible
officer for the TB programme is an Assistant DGHS (TB). The NTP is located
administrative side, it is
within the technical arm of the MOH/FW and on 1the
-- ----coordinated by a Joint Secretary who is responsible for its financial and
administrative control.
National Tuberculosis Progremnie Policies. The long term objective of the NTP
is to reduce tuberculosis in the country to the level where it ceases to be a
public health problem. To accomplish this objective, the NTP focuses on 1)
the BCG vaccination of infants, 2) the detection of the maximum number of
tuberculosis patients among out-patients attending health institutions, and
3) the efficient treatment of identified tuberculosis patients, all as an
integral part of India's general health services.
■€
administrative officers for drug procurement, international assistance,
monitoring of monthly reports, annual planning and coordination with the
National Tuberculosis Institute (NTI)*. Currently, the post of programme
director (Assistant DGHS-TB) and one of the two medical officer posts are
vacant. The level of the programme director is lower than that of other
programme directors (EPI, Leprosy) and below the level of the director of
NTI. This, plus the fact that two out the three central level posts are
vacant reflect the low priority given to the NTP and show the absence of
strong national leadership. This situation, if maintained, would Jeopardize
any attempts to revitalize the programme.
The Central Unit is responsible for drugs forecasting, purchase and
allocation, the annual planning and participation in the discussions of the
HOH/FV with the planning commission to determine the annual and 5-yearly
"plan budget" of the NTP, and for liaison with international agencies (WHO,
SIDA), with NTI, and with state TB programmes. The central unit docs not play
any significant role with respect to tuberculosis control technical policy,
training and manual preparation, monitoring and supervision, These
responsibilities have been progressively taken by NTI. NTI management,
however, is virtually Independent of the NTP. Additionally, State
Tuberculosis Officers are State employees, and they are not accountable in
practice to the ADGHS (TB).
NTP budget. The MOH/FV budget is composed of a "non-plan budget" used for
personnel, salaries, hospitals, etc and a "plan budget", allocated by the
Planning Commission for future investments or creation of new posts. The
"non-plan budget" is not controlled by the NTP and fluctuates minimally from
year to year. No detailed information could be made available to the review
team about the proportion of the NTP budget corresponding to the "non-plan"
budget nor a breakdown by States of the NTP budget and its trend. The 1992
(March 92 - February 93) plan-budget of the NTP is R 145 million (US$ 5.3
million) of which R 110 million - more than 75X - are used to purchase drugs
and 25 million for other expenses such as X-ray units and films, microscopes,
vehicles, etc. Anti-tuberculosis drug costs are shared on the average on a
50:50 basis between Central and State governments. Within the overall NTP
budget, the Central government also provides anti-tuberculosis (hugs to
voluntary organizations, and supplies, equipment, and drugs to the Union
Territories.
Other TClQUrces. The Swedish International Development Agency (SIDA) has
provided funds through WHO. These funds have been used to purchase x-ray
units with Odalea cameras, miniature x-ray film rolls, vehicles, anti
tuberculosis drugs and microscopes. Occasionally, District and State
tuberculosis associations provide anti-tuberculosis drugs, materials and
equipment to specific district programmes or local tuberculosis facilities.
National Tuberculosis Institute (NTI).
The National Tuberculosis
Institute (NTI), located in Bangalore, is responsible for training NTP
personnel, monitoring the programme and conducting operational
research studies. Each year, NTI organizes two 10-week courses. In
1991, for example, 166 health professionals were trained. Apart from
training DTC teams, the NTI also provides refresher courses for
persons working for district tuberculosis control programmes and
and
teachers from medical colleges, etc.
Lastly, the NTI collaborates
with the World Health Organzatlon (WHO) for international training
efforts.
16
2. State level. India is administratively divided into 25 States and 7 Union
Territories. In the State MOH/FW, the NTP is under the Director of Medical
Services, Health and Family Welfare and the Director of National Programmes.
All States have a State Tuberculosis Officer (STO), usually assisted by a
staff of 6 to 10. The vast majority of STOs have been trained at the NTI.
In principle, there is a meeting of all STOs at the central level once a
year.
Responsibilities of the State Tuberculosis Officer (STQ1* The STO is
responsible for negotiating for the State the amount of drugs provided by the
central government and monitoring drug distribution to the Districts. He is
responsible for the overall supervision of District Tuberculosis Officers
(DTO) and through them of Peripheral Health Institutions (PHI). Lastly, he
should organize and coordinate training activities at the State level, in
conjunction with the State Tuberculosis Training and Demonstration Centres
and with NTI.
State tuberculosis demonstration and training centre (STDTC). Seventeen
states have training and demonstration centres. These centres were created
in the early sixties to supplement NTI. They have an average staff of 100
people with about 30 professionals. In addition to training, they have
responsibilities in diagnosing and treating patients and have, in some
instances, research activities. In practice, however, the vast majority of
these centres do not have an organized training programme or research
activities and operate solely as District Tuberculosis Centres (DTC).
3. District level- The District is the basic demographic, economic,
administrative and political unit in India, The District is further divided
__ and Community
__
into Taluks
Development Blocks. One District encompasses 1,800
to 2,000 villages, has an average population of about 1.5 million, and a land
Institutions in the District
area of 10,000 square kilometres. Health institutions
generally include:
1.
2.
3.
4.
5.
One district hospital in the headquarters town.
Community Health Centres (CHC). Usually one in each Taluk, with
several doctors and specialized services (about 10 CHC per
district).
Primary Health Centres (PHC). In principle, one in each comtnunity
development block (about 40 per district).
Varying number of sub-centres (180), other peripheral health
institutions, dispensaries, maternity and child welfare centres,
employee dispensaries, and private hospitals.
Specialized tuberculosis institutions. Tuberculosis clinic, DTC
where the DTC has been Implemented, sanatorium (about 100 beds per
district).
- With one CHC per 100 000 population
and1 one PHC per 30 000 population,
y
have
about
10
to
15 CHCa and 50 PHCs. The country is
an average district may I-------- network
of
21
805
PHCs
and
137
683 sub-centres (Figure 2).
covered by a 1------ — — —
>5
17
Figure 2
ADMINISTRATIVE ORGANIZATION AND HEALTH SERVICES
ORGANIZATIONAL LEVEL
HEALTH SERVICES
Number
- Average Population
National
Institutes
850 000 000
State
Hospitals
25
Sanatoria
34 000 000
State TB Centre (STTDC)
District
District Hospital
438
District TB Centre (DTC)
1 500 000
2 000 000
Taluk
Community Health Centre (CHC)
appr. 15 per district
Central Hospital
100 000
ConMunitv Development Blok
appr. 40 per district
30 000
40 000
villages
1800 - 2000 per district
- 700 - 800
Primary Health Centre (PHC)
Maternal and Child Welfare Centres
Employee and Panchayat Union
Dispensaries
Subcentres (each 4-5 villages)
with Multipurpose Health Workers
18
In addition to these services, it is estimated that there are 330
tuberculosis clinics in operation in urban areas to provide services for the
local residents. Approximately 47,000 hospital beds are available in the
country for the in-patient care of seriously ill tuberculosis patients.
In the district, curative medical services and hospitals are managed by
the District Medical Officer (DMO) and preventive services and primary health
care by the District Public Health Officer. Although the District
Tuberculosis Officer (DTO) works under the authority of the DMO, he has no
formal control or authority over the district hospital and specialized
institutions. Conversely, he controls and supervises tuberculosis activities
in PHIs although these institutions are under the administrative authority of
the District Public Health Officer. This situation means that the DTO cannot
exercise leadership to improve the quality and coordination of tuberculosis
control activities in hospitals and does not have the line of authority
required to properly manage control activities in peripheral institutions.
District Tuberculosis Programme (DTP). In 1991, District Tuberculosis
Prngrnmotes were in existence in 378 districts out of 438 districts in the
country (86X). In a district, all health institutions which undertake case
finding and treatment for tuberculosis are considered as participating units
of the DTP. These institutions are classified as either DTCs or PHIs. Each
district participating in the DTP has one DTC. Sub centres do not have
medical officers and are not considered as part of the DTP network.
District Tuberculosis Centre. DTCs maintain the patient case registers,
manage the recording and reporting system and are responsible for supervising
the TB activities of the PHIs. The DTCs also serve as referral centres to
PHIs for X-ray examinations. They have X-ray units, microscopes and
vehicles. They receive funds for drugs, gasoline, car maintenance, etc. from
the State. Anti-tuberculosis drugs are supplied by the national Central Unit
to all districts including those where the NTP has not yet been implemented.
Most DTCs receive additional drugs directly from the State. DTCs have a
staff of 15 to 20 persons including the District Tuberculosis Officer (DTO),
one to three tuberculosis medical officers, one radiology technician, one
laboratory technician, one to five treatment organizers, one statistical
assistant, one pharmacist, and one or two drivers.
Peripheral Health Institutiona (PHU. In the District, most. CHCs and a
number of PHCs staffed with at least one doctor are selected as PHI to
implement the NTP and conduct diagnosis and treatment of tuberculosis, There
are 3 types of PHIs:
1.
2.
3.
X-ray centres, offering X-ray and microscopy
Microscopy centres, offering microscopy only
Referring centres, preparing sputum smear for or referring patients
to the nearest microscopy centre.
No special staff is posted at PHIs and the Medical Officer in charge is
responsible for tuberculosis activities. In some instances, one of the
health workers of the centre (microscopist, X-ray technician) takes
responsibility for tuberculosis patient management.
Multipurpose Health Volkers (MPHW). In all PHIs there are multipurpose
health workers who represent the most peripheral level of health care
e
are usually based in subcentres, in pairs. With respect to tuberculosis, th y
are to maintain a list of all patients on treatment, to visit them regularly
and to refer symptomatic patients to the nearest PHI or the DTC. They are
not currently responsible for distributing or administering anti-tuberculosis
drugs.
</
19
UrbflD tuberculosis control* There are e multiplicity of urban organizations
and institutions Involved in tuberculosis control activities, both public and
private. These organizations, however, rarely coordinate their efforts and
often work in isolation and/or overlap activities. Consequently, areas
and/or population pockets needing tuberculosis services may be overlooked and
manpower and financial resources are not well utilized. Since 1975, city
tuberculosis programmes are to be organized in a similar fashion to DTPs,
with the stipulation that each city programme would be tailored to the
administrative, operational and social conditions of the specific city.
Currently, however, only a few large urban areas have well-functioning
tuberculosis programmes. Voluntary organizations and tuberculosis
associations have been able to augment city tuberculosis programmes in many
instances by providing technical and financial support, health education, and
community outreach.
Conclusions:
The NTP has a very weak central structure, which for a long time has not
provided leadership in establishing and updating policy and technical
procedures and assuming programme direction. As a result, programme
procedures have stagnated and the original philosophy of the NTP has not been
fully implemented, or revised to make full use of the development of PHC. The
functions and resources of the State level, in particular training, have not
been developed and properly utilized. In most large urban centers the
coordination of activities among diffrent institutions, under the guidance of
the STO and STDTC, have not yet been implemented. In a similar way, the
curative services (hospitals, etc.) and preventive services (PHIs) are not
coordinated at District level in a single network for TB control, and the
lines of authority of the DTO are not clearly established. The extension of
TB diagnosis and treatment activities to the community through the MPHW has
been slow, and that valuable human resource is not sufficiently utilized to
enhance access to care and patient compliance to recommended therapies. There
is no technical and policy advisory body to lend credibility and promote
visibility of the programme to government agencies and potential donors and
to provide support to the national team in the preparation and periodic
updating of national policies, technical and administrative procedures, and
monitoring and evaluation of the programme.
6, CASE FINDING AND DIAGNOSIS
Diagnostic services provided by the NTP are free of charge for the
patients. A major stated objective of the NTP is to detect the maximum number
of tuberculosis patients in the community and among outpatients attending
health institutions with symptoms suggestive of tuberculosis, giving priority
to sputum positive patients. According to NTI manuals, the principal approach
of case finding should be routine screening by sputum smear examination of
chest symptomatic patients attending health centres, and symptomatic patients
be referred for x-ray only after a negative sputum examination has been
repeated. In practice, however, this policy is not followed.
Patients with respiratory symptoms attending a public outpatient
facility are investigated with chest x-ray and generally one sputum smear
examination. Patients who have to come back a few days after their initial
exams are not routinely requested to bring an overnight sputum sample, Often
diagnostic smears are not done or the results are not recorded on the
treatment card. PHIs without x-ray facilities refer sputum negative patients
to a peripheral x-ray centre or to the DTC. Looking for better care or
because of public transport facilities, which directly link to urban centres,
many patients bypass the microscopy centre and go directly to an x-ray centre
or hospital, adding to their workload and increasing the proportion of cases
diagnosed through x-rays.
20
Most facilities with X-rays diagnose the patients and initiate TB
treatment on radiological evidence, in spite of a negative smear examination.
Very few facilities indicate further sputum examinations, or treat smear
negative tuberculosis suspects with non-specific antibiotics and follow-up
the patient's clinical and radiological evolution prior to initiating anti-TB
therapy, suggesting overdiagnosis based on x-rays. Overall, approximately 20X
of patients diagnosed with tuberculosis have at least one positive smear, a
very low proportion compared to the expected capacity of smear examination of
diagnosing 40-60X of all TB cases. The practice of doing generally only one
diagnostic smear examination is probably resulting in infectious cases being
treated as noninfectlous (with inadequate regimens and supervision) or not
diagnosed at all. Official data published for one state tuberculosis
programme showed that between 1969 and 1987 the total number of tuberculosis
cases almost doubled whereas the proportion of smear positive cases decreased
from 61X to 28X, suggesting that clinical practice is relying less on
bacteriology and further separating from the policies recommended by the NTP.
Unfortunatelly, outpatient facilities run by non-government
organizations (NGOs) generally follow the sane routines. Moreover, NGO
institutions and municipal health facilities were found to charge
registration fees for each visit. In private practice, patients have to pay
for consultations , smear examinations by private laboratories and the
prescribed nedication.
It is estimated that up to SOX of tuberculosis patients are identified
and at least partially treated by private practitioners. These patients do
. not initially enter the NTP and are not registered. Many patients then move
to the public sector because of the cost of care and drugs. Thus, a large
proportion of patients attending a health service facility have previously
been seen by a private practitioner.
Due to the high number of PHIs in the district, the maintenance of an
updated cross indexing system at DTC is complex. Patients may not be able to
provide a complete address due to illiteracy or type of dwelling or because
TB has a social stigma and the patient does not want to receive mail from the
DTC or visits from DTC staff. Unless they present an identity card issued by
a public institution, patients previously treated outside the public system
or which are not found in the DTC cross index are diagnosed, registered and
notified as "new" cases. This practice correctly Incorporates new cases
initially detected outside the public system, but duplicates notifications if
the patient was detected by a public institution outside the District.
A more serious problem is that the clasification in "new" or "old" bears
no relation to the previous treatment history and is not useful to decide on
patient therapy. If the patient is not found to have been previously indexed
in the DTC, he is considered "new" and is given a regimen for new cases. The
insufficient definition of "new" and previously treated patient leads to the
prescription of wrong regimens. A significant proportion of previously
incompletely treated cases is known to have acquired resistance to isoniazid
and streptomycin. The efficacy of "conventional" chemotherapy for such cases,
who are most likely still symptomatic and smear-positive, is very low.
Laboratory facllltiea
Most laboratories visited were equipped with monocular, rather than
binocular, microscopes without an electric light attachment. Some of the
microscopes were in poor condition and the light source appeared to be
inadequate. The quality of slides varied and some slides were found to be
uneven and poorly stained. Acid fast bacilli could not always be found in
smears read as positive. An ocular magnification ratio of five or six was
routinely used rather than the usual 10 ratio. As definitions for data entry
21
are irregular, laboratory registers to not permit determination of the
proportion of new cases, re tree tmer.t cases and follow-up examinations. Sputum
smears are not routinely used fcr mt r.itoring of treatment outcoa-e .
Many laboratory technicians •ur-.ing in peripheral micrrscopy centres
have been trained for the malaria ::r.trol programme and are not.familiar with
sputum smear examinations. Malaria stears are often given a higher priority
and may constitute a high case lead. The number of sputum smears to be read
by one technician per day is usually considerably less than 20 except in
larger institutions such as DTCs and major hospitals. The rate of positive
smears varies between 1 and 10Z. These low positivity rates may be partly a
result of poor selection of symptome tics, poor quality of the samples, low
quality microscopes, weak laboratory practices, inadequate treir. r.r and an
excessively limited exposure to tuberculosis smear slides due to & small
catchment area. The supply of chemicals was adequate and no shortages were
reported. Slides with negative smear results are often reused, as indicated
in the NTI manual, with a risk of false positive results.
Quarterly or semi-annual supervisory visits are made by the DTC team to
assess the performance of the laboratory staff, The supervisors check
usually only all the positive slides, retained at the microscopy centre for
reading. Notes on the supervisory observations made, such as the proportion
of false positive and false negative readings, were not available for
scrutiny. There is no system of quality control through sending slides to the
DTC or to a State reference laboratory. Laboratory staff are often in need of
re-training and staining is of varying quality. Few States have functioning
reference laboratories to train District staff, supervise DTC laboratories,
carry out sistematic quality control of smears and do sputum culture and
sensitivity testing when necessary. In one State it was observed that the
STDTC laboratory had different procedures for smear examination that those
recommended by the NTI manuals and utilized by the DTC laboratories in the
State.
X-rav practices
With very few exceptions, diagnosis in clinical practice is based on the
chest x-ray. Even with one negative smear or no smear result, tuberculosis
treatment is initiated if the x-ray appears suggestive of active pulmonary
tuberculosis. The x-rays taken in referral centres are usually kept at these
facilities. The referring PHI only receives a note with the x-ray result.
The standard equipment In most x-ray units is an ODELCA camera with 70 or 100
mm films. In soma hospitals, standard size films are used. Chest clinics at
the district level use both small and standard size x-ray films. Most of the
technicians are sufficiently trained and the chest films are of a good
quality, but complaints were expressed about the quality of the domestic
films. X-ray centers had well functioning x-ray units and usually sufficient
film to handle the tuberculosis caseload within the centers, although
temporary shortages of x-ray films are commonly experienced by PHIs. 93X of
x-ray machines were in working order at the DTCs as of 1991 (13) . Assessment
by an inexperienced reader of the small size x-ray films widely used for
diagnostic x-rays or use of slightly inferior quality films can lead to an
increase in overdlagnosls.
Conclusions'
The NTP has an Infrastructure tf microscopy and x-ray centres,
integrated into the primary health care system and staff are available to
perform case finding activities down to the village level of health care
delivery. Major weaknesses of the NTP with regard to case finding are that
usually only one or no sputum smetr Is obtained before a tuberculosis
diagnosis is made, and that dii.— if.i is primarily based
e results of a
I V
22
chest x-riy. This practice results In significant underdiagnosis of: smear
positive cLsti zy smear examination and in treatment of infectious petier.ts
as smear neget ve cases with inappropiate re cimens, and discourages
monitoring of :rtatment outcome by sputun £Z‘Lr results. Patients with
assessed and treated before the
respirator}* sy iptoms are often inadequate
xede.
The lack of vigorous
negative
tuberculosis
is
diagnosis of smear
the
tendency
to rely on x-rey
patient
management
increases
procedures
negative
tuberculosis,
cr
smear
examinations resulting in the overdtagnosis
registers
result
in multiple
case
Inadequate case history and the impractical
diagnosis of defaulters and ovemotification.
The primary* aim in case finding should zt the identification of spu.um
smear positive cases. Before the diagnosis cf tuberculosis and decision to
treat are made, the results of at least two sputum smears should be
available. The role of the sputum smear examination in tuberculosis
diagnosis should be greatly emphasized and the role of radiological
examinations should be reconsidered. For differential diagnosis, the ODELCA
cameras and miniature films for diagnostic chest x-rays may be phased out and
replaced with equipment based on the specifications for the WHO Basic
Radiological System, after carefully working out the cost considerations. For
screening of symptomatic attendees in hospitals of large urban areas to
select patients for bacteriology, small size X-rays may be useful.
The NTI laboratory manual should be revised, used for training at State
level and distributed as a reference to the laboratory staff of PHIs. Wall
posters with the basic procedures for microscopy, as were seen in one of the
States visited, should be made available to all peripheral microscopy
centres. Supervision of DTC laboratories should be undertaken by State
reference laboratories. Supervision at State and at District levels should
include a system of quality control whereby samples of positive and negative
smears are systematically sent to a reference laboratory for confirmation.
Acceptable quality binocular microscopes should be made available. All
diagnostic centres, including those outside the State health services, muse
adhere to uniform programme guidelines.
7, trea:
The manuals for the District Tuberculosis Programme (NTI, 1990) include
the current national policies for the treatment of tuberculosis. The
Introduction Manual states that free chemotherapy should be provided to self
referred tuberculosis patients. The highest priority is given to treatment of
sputum positive cases to reduce the transmission of Infection in the
conounity. Five regimens of "conventional chemotherapy" of 12-18 months
duration for all forms of tuberculosis are recommended. In a phased manner,
two short course regimens of 6-8 months duration are to be provided for
sputum positive cases. Patients are "allowed to collect drugs from the
nearest PHI and are motivated to consume drugs for prescribed duration
regularly".
In Annex 4.1 the regimens j
found1 to be most frequently used in the DTP
are presented according to the currently
(------ - recognized category of patient and
priority given if drugs are available. The categorization used in the
following sections of this report corresponds to that used in the WHO
Guidelines for Treatment of Tuberculosis in NTPs. However, in the India NT
manuals, the seven recommended regimens do not always refer to the specitic
category of tuberculosis patients and the‘choices of regimens are not
prioritized.
23
Treatnenc practices.
Patients are mostly treated by "conventional" regimens on an ambulatory
basis and oral drugs are self administered by the patient. In some States
(mostly in the South of the country) the regimen of HT is rarely utilized due
to the reported high frequency of side effects. There, most patients are
treated with HE for 18 months or SH twice a week. In some States of the North
where thiacetazone is well tolerated, the drug is not supplied in sufficient
quantity because of shortages in the national market attributed to the low
profit margin on the drug for the pharmaceutical companies.
SCC regimens for pulmonary smear-positive patients are theoretically
Implemented in approximately fifty percent of the districts in the country,
but in reality only a minority of patients are treated with SCC so far. SCC
is being implemented slowly, mainly because the expansion of SCC has not been
given high priority in the NTP. The selection of patients eligible for SCC
observed during the review is quite strict, probably because the medical
officers of the DTP have doubts about the compliance of patients in self
administration of the SCC regimens. SCC drugs are often kept at the DTC or
selected PHIs and patients living far away cannot come twice a month for the
drug collections.
The treatment is usually prescribed by a medical officer of the DTC or
PHI, and provided free of charge. Anti-tuberculosis drugs for the recommended
regimens, in particular for SCC, are periodically out of stock, reducing the
motivation of the patient to regularly attend the institution and
contributing to the prescription of a non standardized regimen. Patients
attending private clinics are required to pay for their medications. They may
go to governmental institutions when they are unable to continue to pay for
treatment, but do so only when they are very sick. In a limited number of
situations, treatment may be supported by voluntary organizations. Often when
there is a shortage of one or more drugs in the health centre, patients are
required to buy the missing drugs. In one State, streptomycin, part of the
"conventional" regimen, was presently missing in most centres visited by the
review team due to a SOX budget reduction from the previous year's budget.
PaCients vith severe fonas of tuberculosis (e.g. Meningitis), those with
complications of tuberculosis (e.g. pneumothorax, hemoptysis), those vith
tuberculosis complicated by other diseases and failure «of an initial regimen
requiring retreatment are hospitalized. Places of hospitalization are
referral hospitals including sanatoria and medical colleges. Seldom are
tuberculosis patients hospitalized in CHCs or district hospitals.
Hospitalized patients frequently receive "conventional" chemotherapy that has
low efficacy for critically ill and retreatment cases.
Existing hospital
beds for tuberculosis are utilized for advanced disease and not fully
utilized to prevent treatment failure. Hospitalized patients often receive
weak regimens and the beds are therefore not utilized in a cost-effective
manner.
In the DTC, drug collection is done once a month for "conventional"
therapy and twice a month for SCC regimens. The frequency of drug collections
by the patient is similar during the initial and the intensive phase of
chemotherapy. Streptomycin is administered in the health institution nearest
1 to the patient home or by a private nurse. Usually the patient does not see
the medical officer during the follow-up. He may be asked to see the MO if he
has drug side effects. The monitoring of side effects is not systematic and
there is little information regarding the percentage of patients who may have'
experienced major side effects.
I
■
24
Guidelines for changing regimens during chemotherapy or for prolongation
of the duration of a regimen have not been issued by the NTP, creating
confusion, particularly for MOs in the PHIs. Unnecessarily long conventional
regimens are a burden for the patient, causes an unnecessary workload for the
staff, and results in drug wastage. The decision to discharge from treatment
is made by the MO on the basis of the treatment card and on the clinical
condition of the patient. Criteria for discharge from chemotherapy are not
clearly specified in the NTP manuals. The patient is permitted to stop
chemotherapy when he has completed 80Z of his prescribed regimen. If he has
not completed such a course, he has to continue the treatment for the
duration of time for which he has not collected drugs. Due to the high
incidence of defaulting, most patients receive unnecessarily long regimens.
In addition, the definition of treatment failure is not clearly specified nor
is practice uniform among MOs working in the PHC centres with regards to how
to manage a failure case.
After treatment completion and discharge, the patient is instructed to
return every 3-6 months for follow-up. This practice is unnecessary and
results in wasting of effort for both the patient and health staff.
Treatment organization.
Smear examinations are not repeated during conventional chemotherapy, to
confirm that the patient is really sputum negative or to determine sputum
conversion in smear positive patients. For SCC regimens, NTI recommendations
do not require sputum examination at the end of the Intensive phase of
chemotherapy nor are criteria specified for prolongation of the 2 months
Initial intensive phase if the patients remain smear-positive. Smear
examination after the Initial intensive phase of SCC is required in some
centres participating in the Tuberculosis Research Centre operational trial,
but is done in approximately 20X of the patients only. The insufficient
monitoring by sputum examination during chemotherapy does not allow for
evaluation of the outcome of the initial intensive phase of SCC chemotherapy.
Patients who are still smear-positive at the end of the initial phase should
receive special supervision by the DTP staff because they may not have
strictly adhered to the prescribed medications. These patients may still be
' cured by the same regimen for new cases if the drugs of the initial intensive
phase are continued for an extra month and the staff fully supervises the
patient.
National policies require that pulmonary patients be monitored by x-ray
examination after six months and at the end of conventional chemotherapy.
This requirement is not necessary in smear-positive patients and is not costeffective in smear-negative patients. In practice, only a fraction of
pulmonary cases are followed up by chest x-ray films in the DTP.
Extrapulmonary tuberculosis patients are monitored by physical examination
and by appropriate clinical tests.
The decentralization of the treatment of tuberculosis patients to PHIs,
as recommended by the NTP, is not fully utilized for the administration of
SCC regimens. The lack of decentralization results in a high percentage of
dropouts. A significant percentage of patients diagnosed in DTCs are
defaulting the first drug collection. The treatment card is not opened nor
. are the name and address of the identified smear positive cases in the
community communicated to the PHI closest to the patient’s home to retrieve
the patient-. Name and address of patients under treatment by the DTC or other
institutions are also not routinely communicated to the PHI.
In PHCs, the MO at the beginning of treatment and the pharmacist during
follow-up should provide patient motivation. At present, the same effort is
made for all categories of patients, without sufficient focus for smear-
25
•)
positive cases of TB that are the priority for cure. In DTCs, the DTO and MOs
should provide motivation at the beginning of treatment and the treatment
organizer should do so during the follow-up. Sometimes, in training and
demonstration centres, health education and motivation is provided to small
groups of patients. There is no formal monitoring of the effectiveness of
such practices. There is no special effort to re-motivate patients who are
still smear-positive at the end of the initial phase of SCC, when there is
still a high probability of smear conversion and cure if the drugs are taken
regularly. Effectiveness of health education practices among the patients and
among the community are seldom evaluated and health education material is
rarely available among patients, family members and health staff. Not enough
emphasis is put on informing the patient and the health staff about the
importance of sputum examination.
Follow up of defaulters is not practical because the staff is required
to take action for a large number of patients, without focusing on those who
remain smear-positive during chemotherapy. The current guidelines recommend
that priority be given to sputum positive patients, leaving to the DTO the
decision of excluding sputum negative patients from defaulter action. If home
visits cannot be done, guidelines require that letters be mailed twice: after
three days of defaulting and after 11 days if the patient is still
delinquent. During the review it was found that letters are the most common
action to retrieve defaulters. However, a large number of patients provide
incomplete addresses and therefore reminder letters cannot reach them. In the
PHC, the multipurpose health staff are sometimes asked to retrieve the
patients, but such action is probably not stressed enough by the medical
superintendent and Chief Medical Officer. The village health worker Is often
not Informed about the TB patient(s) living in the village. The PHC is also
not systematically informed by the DTC about new patients diagnosed and
remaining under treatment by the DTC or hospitals.
The reasons for defaulting are well Identified by the tuberculosis
programie staff. Among the most important is the fact that the patient loses
interest once he becomes asymptomatic. Disruption of drugs stock, incomplete
provision of the first line drugs for "conventional" and SCC, long waiting
time, inability of the system to adjust to the patient needs, distance of DTC
or hospitals from the patient's home are the other most common reasons for
defaulting. Some patients go to a health institution different from where
they are registered with the hope of receiving better care. This increases
default as well as making it more difficult to retrieve them. The DTC and
other specialized institutions do not use auxiliary staff (MPHV) to retrieve
defaulters and do not inform PHC of the existence of patients on treatment
from that area.
Among defaulters, approximately BOX to 50Z miss drug collections before
the fourth month of chemotherapy. 5X of patients default after diagnosis is
made and before therapy is initiated. In some instances, the patient is not
informed that he has tuberculosis and should be treated. Lack of motivation
of staff, weak leadership of the medical officer and little accountability to
the chief medical officer for tuberculosis have been Identified by the
supervisory teams as additional reasons for patient defaulting.
In the policies cf the NTP there is no target for treatment completion
and cure of pulmonary smear-positive patients. In such patients the fatality
rate is known to be high and irregular chemotherapy leads to drug resistance.
The present policies and practices are insufficient to reduce the spread of
the infection, particularly of drug resistant mycobacteria, and the mortality
due to tuberculosis. The observation of the assessment teams show that the TB
programme obj-ectives are not efficiently prioritized. The existing health
infrastructure and resources available are not fully utilized to sterilize
smear-positive patients as quickly as possible. In a significant proportion
26
of the sources of infection diagnosed by the DTP, the chemotherapy is not
started, and a large percentage of smear-positive patients put under
treatment drop out during chemotherapy.
The decentr£ 1 it£.tion of the programme is not achieved. Guidelines for
patient management are not present at the level of peripheral health
institutions (PHC ant CHC for a population of 100.000 to 200.000) where most
of the patients could benefit from the existing health services. Medical
officers working in PHCs and CHCs are generally not trained for the proper
management of the tuberculosis patient. Supervisory visits to PHI from DTC
•and chief medical office are not targeted to Improve treatment outcomes.
Conclusions:
NTP policies and procedures on treatment do not reflect the WHO
recommended emphasis on short course chemotherapy and patient registration
systems which facilitate the monitoring of completion and cure rates of
patients on anti-tuberculosis treatment. The tuberculosis programme at the
delivery level does not adequately emphasize the importance of treatment
completion as the main index for programme evaluation. During the programme
review, the teams observed that DTP practices depart from what should be done
to effectively treat tuberculosis patients. Service delivery focuses on case
finding activities and not on treatment completion and cure. Tuberculosis
staff are not optimally utilized to enhance treatment completion activities.
Additionally, there is no good system to evaluate treatment results. NTP
policies and procedures should be revised to ensure that the most efficacious
and current treatment regimens are recommended, including fewer regimens and
short course regimens where appropriate. Registration systems should solicit
data to monitor completion and cure rates, with particular focus on smear
positive tuberculosis patients.
The main goal of the NTP should be to
ensure that patient completion of anti-tuberculosis treatment and cure be
reflected in all policies and procedures and that such be carried out in the
current integrated health care delivery system. Guidelines for treatment
organization are attached in Annex 4.2.
8. PROGRAMME MANAGED
8,1 CASE NOTIFICATTOM
Tools for progrnw monitoring are the treatment card, the laboratory
register, the master book of treatment cards (MBTC), the cross index card,
the patient identity card and the report on treatment results. The use of
register books and report forms is in accordance with the NTP guidelines in
DTCs where the statistical assistant is in position and has been trained at
NTI. However, training courses have been rarely repeated and trained staff
have been transferred to other programmes within the district. The format of
the treatment registers is not always standard, as they are copied by hand
and not printed, and the content does not Include all the data required to
analize the results of treatment. The card is sent from the PHI to the DTC
when the patient completes treatment, defaults or dies, so the MBTC is the
only source of data on treatment left at PHI level.
The usefulness of the recording and reporting system does not appear to
be well known at all levels of the system. Consequently, evaluation of
programme outcome and actions are missing, and the evaluation by cohort
analysis of results of treatment is often not done. Cross checking of
patients registered in the laboratory register, the treatment card, and
registrations in the MBTC is not operating efficiently. Therefore no action
is taken for smear positive patients registered in the laboratory register
who default from the first drug collection, data on initial defaulters are
not available and the information in the cards and MBTC is not complete.
. r'-1
27
Cone lur i ?r.3 •
. r.e current reporting and reccrdir.g system for the NTP is cumbersome and
does not address the main VHO recommended objective of the programme. i.e.
mer.i
the mt
r.. re ring of the cure rate extr.r in ear-positive cases of tuberculosis.
Cohort £-.£lysis does not cover all rm*tr-positive cases diagnosed and is not
done at rhe PHI level. The current bTP system of registration and
notification should be revised to facilitate recording of essential data,
such as previous history of TB treatnent, and emphasize the collection and
cohort analysis of treatment results as rhe main indicator of programme
effectiveness.
A printed copy of the laboratory register and patient register books
should be made available to each PHI implemented to provide tuberculosis
care. These registers should be kept by a PHI staff trained in record keeping
and should be supervised at least every two months by the DTC supervisor.
Supervisors should cross check the records in the registers to assess the
consistency of the data. Standardized reports on the indicators of programme
performance should be filled out at the end of each quarter and forwarded to
the DTC. The DTC will consolidate the reports from the PHIs and forward them
to the state TB Office. DTC team supervisory visits to PHIs should be
prioritized on the basis of performance.
8.2 SUPPLIES AND TRANSPORT,
Anti•tvberculQsia drugs
Anti-tuberculosis drugs used by the NTP are manufactured or compounded
by pharmaceutical companies within the country. In principle, SOX of the
anti-tuberculosis drugs for the NTP are purchased by the national government
and SOX by the States. The national government negotiates with the states
its financial contribution for drugs based on the capacity of the State to
complement the central government contribution. The amount of drugs needed
by each state is determined annually by the central unit from the number of
; patients reported the previous year, the population, and the requests
received from districts. These requests are initially scrutinized at the
state level. The central unit negotiates the purchase of drugs with the
pharmaceutical industry but it must buy from semi-public corporations as long
as the drug price is no more that 20X higher than the price of private
companies. The distribution of drugs to the districts is the responsibility
of the Medical Store Organization.
. **
The State portion of the anti-TB drug supply is generally purchased by
the District from manufacturers selected in State bids, using allotted State
funds and sent to the District directly by the drug manufacturer. Monitoring
of stock supply, reserve stock, and usage is left to the District. Although
the districts send notification of supplies on hand, usage, and drug
projections to the STO, it is unclear whether analysis of usage patterns is
regularly undertaken at the State level. Facilities are likewise unaware of
drug supplies available in neighboring facilities or institutions.
At the district level, the DTO usually estimates the needs of antituberculosis drugs on the basis of the previous year's consumption. He
receives the drugs purchased directly by the central government and the
budget allotted by the state through the chief medical officer. In some
situations, the budget obtained from the State to purchase anti-tuberculosis
drugs was sufficient for only a fraction of the needs, due to Increases in
drugs costs (approximately 20X compared to the previous year). In some
districts, the funds were sufficient, and if additional funds were necessary,
they could be requested from the state. In some Instances, shortages were
corrected by using funds from TB associations, Interrupted supply of some
•)
2B •
anti-tuberculosis drugs at district level were noted as being due to late or
incomplete supply by the production laboratories of approved orders or due to
the absence of reserve stocks at the state level. The state does not purchase
or receive drugs directly nor does it maintain a buffer stock. *
The rifampicin used by the NTP is net a combination capsule. Fixed dose
combinations of rifampicin with isoniazid, and -.'ith isoniazid and
pyrazlnamlde are however available in the tLarktc. The quality of such single
drugs and combination drugs is not currently being monitored by the NTP.
Conclusions■
Ensuring an uninterrupted supply of anti-TL drugs to the tuberculosis
patient should be a key function of the national and State tuberculosis
programmes. Shortfalls in funding and delay of drug supplies from the
pharmaceutical industries can be compensated by 1) closer monitoring of usage
patterns, drug purchase projections and stocks by the STO and 2) establishing
a buffer stock at the State level sufficient to ensure at least a 6 month
supply of uninterrupted drug distribution to the districts. Similarly,
districts and PHIs should maintain Internal buffer stocks of three months as
an additional preventive measure. Estimations of the amount of buffer stock
should be based on the number of patients reported during the previous year.
In addition, drug quality should be monitored by the National Unit and the
States through a selected scientific institution.
'
Transport
The non-availability of road worthy vehicles and poor budget allocations
for fuel have been cited as reasons for limiting the number of supervisory
visits by the DTC team to PHIs. At District level, fuel quotas were clearly
insufficient, in view of the increased number of PHIs to supervise and
distances to cover. As a result, supervision of PHIs is not done with the
frequency required, or several PHIs are supervised in the same trip with
insufficient time allotted to each one. Adequate provision of fuel should be
provided to the DTC for supervision, and transport should be provided to
district supervisors based at subdivisions! level to reduce milage and fuel
costs.
8,3 SUPOLVISIOW. MOWriQUWG AND EVALUATION
According to NTP policy, the District Tuberculosis Officer and his team
of laboratory technician, x-ray technician, and treatment officer, etc. are
responsible for the supervision of all personnel within their District
involved in tuberculosis activities. The team is expected to visit each of
their PHIs on a quarterly basis. They are to evaluate diagnostic and
treatment procedures, validate laboratory results, monitor record keeping
activities, check on defaulter actions taken, and monitor anti-tuberculosis
drug supplies and support equipment. In addition to their supervisory
duties, the team is expected to do on-the-spot training and/or retraining of
staff, collaborate with other disease control programmes on topics of mutual
interest, and offer continuing education to the general public. Supervisory
checklists have been provided by the NTP to guide the supervision of DTCs and
PHIs. At PHI level, Medical Officers have been made responsible for the
supervision of laboratory technicians and multipurpose health workers.
•;
When the NTP was o peratlonalized in 1962. the District demographic unit
was designated as the basic unit for the NTP. All NTP activities were
conceived and organized at the District level, In the three Intervening
decades, the District has grown in populstior., and the number of government
health services has grown at least in proporti on to the population growth.
r
29
It is increasingly difficult for the DTC team to operate under the
organization conceived thirty years ago, to feasibly supervise and manage at
the District level. In one District visited, with a population of 4 million,
119 out of 148 Peripheral health Institutions have Implemented the DTP. The
DTC staff would have to make 20 visits per month, supervising 2 facilities
per trip in order to provide quarterly coverage for its implemented centers.
This schedule of activities does not include the general hospitals, voluntary
organizations, etc. which also treat tuberculosis patients and should benefit
from regular supervision.
The assessment team noted that the District Tuberculosis team did make
visits to PHIs. The quality of the visits was difficult to assess, and the
frequency and regularity of the visits were difficult to validate, as
supervisory reports were not available for scrutiny. Records were not in
order at facilities where recent supervisory visits were noted.
Alarmingly, there has been a steady decline in the proportion of PHIs
supervised by the DTC team, from 51X in 1983 to 41X in 1991. In 1987 only 84X
of functioning DTPs sent quarterly reports. Of these only 72X ( 60X of
functioning DTPs) gave information on supervisory visits. Of the SOX of DTPs
giving Information, they had supervised only 45X of their PHIs. Thus only
*
The quality of the
27X of the PHIs have been reportedly supervised,
supervision is not known (5).
Currently, supervisory visits are primarily used to evaluate, record
mnxiiucimiivd, laboratory performance,
maintenance,
performance. assess defaulter retrieval activities,
and monitor the supply of anti-tuberculosis drugs and other equipment. Not
only are the supervisory objectives poorly fullfllled, but very little time
is devoted to the evaluation and supervision of programme performance with
regard to the accuracy of case-finding and to patient completion of
treatment.
The National Tuberculosis Institute (NTI) has been responsible for the
monitoring of the National Tuberculosis Programme since 1978. Information on
DTP activities is recorded through a system of records kept at the facilities
and periodic reports sent to the NTI. Peripheral health institutions report
case finding and treatment activities on a monthly basis to the DTP. The DTP
prepares quarterly and annual reports for the NTI, inclusive of data received
from the PHIs involved in tuberculosis activities.
Programme monitoring and evaluation has been largely limited to review
and analysis of notification data and regularity of reports. The current
information system does not provide for the monitoring of treatment outcome
or programsM outcome indicators. Management indicators and monitoring
procedures focus attention on case finding but exhibit very little emphasis
on case treatment and cohort analysis. Additionally, patients who are
hospitalized in the more than 40,000 tuberculosis hospital beds are not
registered in the NTI information system. Likewise, the large number of
patients receiving initial care through the private sector are not registered
with NTI. Consequently, it is estimated that less than 57X of all cases of
identified tuberculosis are registered with the NTI (1).
In 1991, only 378 districts out of 438 with DTPs had registration in
place (86.3X). Of those with DTPs, only 278 out of 378 sent reports (74X) .
Of the DTPs which reported to the NTI, they only received reports from 8502
out of 12,338 PHIs. Results from the 1987 "In Depth study on the NTP of
India" (1) showed a general lack of awareness among tuberculosis staff of the
importance of records and reports. Very few officers have readily made use
of them. Data in the reports was not useful for programmme management
activities. Supervising officials rarely checked records and reports or gave
guidance regarding their proper maintenance. Reports were .very often
30
incomplete and unreliable. Although on site evaluation of case management is
reported, it is acknowledged by supervisors that the monthly and quarterly
reports sent to the DTC are not analyzed nor are the sending institutions
given any feedback as to performance as reflected in the written reports.
Conclusions *
There needs to be a clear emphasis placed on supervision if the NTP
programme is going to succeed. Tuberculosis programme personnel need to bo
retrained about supervisory methodologies as well as supervisory content
which emphasizes programme performance parameters. In order to address the
increase in population and health care facilities at the periphery, a medical
officer or treatment organizer and a laboratory supervisor should be added to
the District Tuberculosis team at the sub-divisional level (about 500,000
population) in order to facilitate decentralization of supervision, staff
training, monitoring and evaluation, and management of tuberculosis programme
activities at the level of PHIs. To reduce travel time and cost, these staff
should be based in a hospital or X-ray centre and they should be provided
with transportation.
Monitoring of case finding and treatment results has hot been
prioritized, is still centralized and is not used at health facilities to
evaluate the quality of programme delivery and implement corrective actions
when necessary. PHIs management staff should be retrained on monitoring and
evaluation methodologies. They should be taught to analyze their own
facilities performance indicators and to take corrective action promptly.
DTC, State and national staff should analyze the quarterly and annual reports
received and provide feedback to the health facilities on the priority
indicators of programme efficacy.
8,4 EDUCATION AND TRAINING
Since 1962, the National Tuberculosis Institute (NTI) at Bangalore,
India has been the main training institution for tuberculosis programme
staff. The various members of the District Tuberculosis Center (DTC) team
(medical officers, x-ray technicians, laboratory technicians,
pharmaclsts/treatment organizers, and statistical assistants) undergo a 10
week training program at the facility, with special emphasis on their areas
of responsibility. The NTI also conducts seminars for state tuberculosis
officer*, nnlv.rilt-v
university facultv.
faculty, and district medical
nedical officers, as well as
refresher courses for DTC staff.
In theory, in addition to NTI, the State Tuberculosis Training and
Demonstration Centers (STTDC) are responsible for training BCG supervisors,
orientation training of health visitors, and training of medical students and
ancillary health care providers on the clinical aspects tuberculosis control.
Continuing education for the private physician is often undertaken with
assistance from the Indian Medical Association and voluntary organizations.
The review teams found, however, that the training given by STTDCs was
neither comprehensive nor consistent with NTI policies and procedures with
regards to diagnosis and treatment recommendations, i.e., x-ray reading,
procedures for procuring and preparing sputum for smear microscopy, treatment
regimen recommendations, etc. Training materials were not available for
scrutiny. Instruction in the STTDC is provided on the basis of observations
of clinical procedures, focusing on clinical aspects rather than programme
operations.
31
Sines th. anphasl.■ «>
"
;“': e5b:*S"ml”" *"ntml effort. Th. training
these health personnel In NTP P.Ucle. *"8
dlstrltts.
»T0 and h . staff
b’“h“.f (mo-day)
..t.rLls. In
training to medical officers
j.i.(,,t.d to institutes of Public Health
other areas, the training has bee" d’le42^ne ve2r « eighteen months for
which provide general courses ranging
fflce^s uhere the tuberculosis
health workers and one ~°nth for “'dl J
Medical officers of PHCs are
ri::xi:.:/’tr“.;
*.:
»
S:r:i:7dU not
„y training
activities for their staff.
c<
1962 over 4 800 team personnel or roughly 900 full teams have
Since 1962. over 4 8
P
as thf>
the nunber
nunber of dl.9trlcts implemented
been trained by NTI start
n
.
nro
_oCed or attain superannuation,
are^""guR
ha. incraasad. and a. s.nl.r
“
“.pJm.nt 't rr.ln.d
not all Of th. dlatr ot mans c
_ £aUy „,ln.d t.an. «hll. SSI
persons. As of 1991. °n^y
-trlct tuberculosis officer (DTO). 76X had
had the services o a ra
trained laboratory technicians. 88X had
r/aSd t^^^iga^zir^ and 59X had trained statistical assistants
(13).
Conclusions:
Training is vital to the
reconnnendations for the NTP.
the proposed changes in progr
training of 1----- -
NTP training should
hnubll^hialth institutes end
These
"train the trainer"
. International and
national training opportunities should be made available for the different
levels of tuberculosis programs# staff.
The NTP manuals should be «vlse^’should bV dZll^e^by NTP for
Review, and standardized educational
tuberculosls control activities
pr.etiU.n.r.,
In pUv.n. ppnoclO
and for patient motivation.
9. PRIVATE SECTO1
102 nrlvate doctors practicing in Bombay, 601 to
According to a study of 102 P
and seek care by private
70X of patients bypass the public h
y
Review team field
physicians when they become ch*Bt Sy“*L°on of paCients seeking care in the
observations suggested that th. Pr°P
lvldenced in th. Bombay study, but
private sector was slightly lower t
TB cases. Although many of
still represent about probably half of
private practicioners have a
th... pnclnne. U«r — “
.?.<> th.
ml. and their “"t8™," ° JLui.n. do net adb.m to any .at r.Sl«.n
rhe NTP
It appears that private pny
v diaenosis was
for TB- care. As in the public sector.dependence on x r y, for11 tuberculosis
.vm.ne.d. C... finding n.thodology and
th„„8‘egl,„.n, „Co».nd.d by
patients vary nld.ly and ar.. usually ~r
„d |.nc to . ph.m.ey
the NTP. Patients are usually given a p
P
At
JD/ S
05829
.
>J
32
for drug purchase, with very little monitoring of patient compliance.
Defaulter action is rarely taken.
The training of general practitioners is currently not adequate and has
not been updated to Incorporate recent advances in knowledge and strategies
* of the NTP. The capacity and organization of medical associations (IMA,
Anti-tuberculosis associations) have not been tapped to provide continuing
education and programme awareness to the private sector. Interviewed members
of the Indian Medical Association (IMA) at State and District level showed
strong support for the NTP efforts. IMA members seemed well aware of the
issues and challenges facing tuberculosis control and were willing to utilize
the organization to promote tuberculosis health education efforts and
distribute educational materials to its members on the topic of TB case
finding and management. The use of health education messages targeted towards
both the private physician and the consumer regarding correct treatment
regimens and the Importance of completing treatment should be tested as a
method to standardize care provided by the private sector.
Conclusions:
A large share of the provision of health services in the country,
including tuberculosis diagnosis and treatment. Is done by private
practitioners. They are, however, not currently Included in the NTP system,
either for notification of patients or standardization of diagnostic and
treatment procedures. The role of the private sector in the care of the
tuberculosis patient needs to be further clarified by the NTP. If Indeed it
is found that a large share of tuberculosis patients seek care in the private
sector, Improved training in medical schools and education of private
practicioners must be implemented to ensure proper diagnosis and treatment
and augment cure rates for patients under private care.
10, RESEARCH
India has a long history of tuberculosis research to improve programme
delivery and treatment efficacy, and much of the Information and experience
obtained has been applied successfully in other countries. The research
Institutions can be utilized to analyze the functioning of the programme and
to test alternatives to improve programme results, in particular organization
of treatment delivery to increase the cure rate. To ensure that the studies
provide relevant information for programme improvement, and that this
information is opportune and utilized, this research should be planned and
supported as an integral part of the NTP. Some operational research projects
have already been discussed before the Review mission. Two major
institutions currently involved in TB research are briefly described below.
The Tuberculosis Research Centre (TRC) in Madras was established in
1956, under the joint auspices of the Government of Tamil Nadu, the Indian
Council of Medical Research, the British Medical Research Council and the
World Health Organization, for studying Initially the efficacy of domiciliary
chemotherapy, in comparison with conventional sanatorium treatment. The
centre was taken over by the Indian Council of Medical Research in 1965 and
made a permanent research establishment. It established that a wellorganised domiciliary chemotherapy with a dally regimen of isoniazid plus PAS
produced results closely approaching those obtained in sanatorium with the
same regimen; a satellite study established that there was no extra risk to
the close family contacts from the infectious case after the start of
treatment. Subsequently, the Centre Investigated various regimens of
chemotherapy In controlled clinical trials, backed up by in-depth laboratory
investigations and solid statistical methodology. Clinical trials of various
regimens of shortcourse chemotherapy that would be suited to Indian
conditions were carried out, and more recently a study on implementation of
. ... >4
33
shortcourse chemotherapy under programme conditions in 18 districts selected
from different parts of the country was initiated. In recent years, a strong
department of immunology and cardiopulmonary function have been added to the
Centre. Finally, the epidemiological unit that undertook a large trial of
BCG vaccine in South India has now been integrated with the Centre. The
Tuberculosis Research Centre has the capacity for undertaking training
programmes that could complement the efforts of the National Tuberculosis
Institute in Bangalore.
The National Tuberculosis Institute was established in Bangalore in 1960
with the objective of developing a suitable programme for tuberculosis based
on operational research studies, training medical and paramedical workers for
the District Tuberculosis Programme and monitoring the Programme through
periodic reports received from the Districts. Based on studies on awareness
of symptoms and action taken and on the Madras TRC studies demonstrating the
efficiency of domiciliary chemotherapy, the NTP was evolved and launched at
the NTI. In subsequent years, operational studies were undertaken on methods
to improve case-finding, techniques for enhancing patient motivation and
thereby enhance case-holding efficiency, and programme organization.
Concurrently, large-scale field studies were initiated to provide information
on epidemiological indicators such as prevalence and incidence of disease,
fate of newly-diagnosed cases under programme conditions, and on the
prevalence of tuberculous Infection and Infection with other atypical
mycobacteria. Thereafter, and in view of conflicting reports about the
efficacy of BCG vaccine, the largest BCG trial ever undertaken was launched
in Chlngleput, South India, to determine the efficacy of two strains of BCG
vaccine at two different strengths.
Conclusions:
As a step towards the reorganization of India National Tuberculosis
Progranae activities, the research potential of the various research
institutions should be evaluated in light of the findings and recommendations
of this review and needs of the NTP for operational research studies.
Operational research to test the feasibility and results of different
technical and organizational strategies to be adopted by the tuberculosis
programme should be an integral part of the revised tuberculosis programme.
11, SITUATION ANALYSIS
Even after three decades of National Programme activities, the
tuberculosis burden on Indian society remains enormous - something on the
order of five million premature deaths in a decade, half of which are among
women, mainly in the reproductive age. This mortality must affect at least
twice that number of Indians with consequent lowered productivity, disability
and perpetuation of poverty. Excellence in research, early successes proving
the advantages of some modern treatments, availability of powerful and
effective antibiotics, a well established TB structure at the State level
and, in the last two decades, extensive development of the Institutional
structure for primary health care in the rural areas, have not yielded the
progress against the disease which India could have expected. Decline in the
annual risk of infection (and in incidence) has been agonizingly slow in many
areas. Well over half the population is infected with TB and the risk of
infection is far too high at between 1 and 2X per year. An aging population
structure, increasing HIV prevalence and apparently rising levels of drug
resistance mean that without a reoriented and vitalized public TB control
effort the disease will pose an increasingly serious health and developmental
constraint for several decades to come.
IIIIIMII
I II
Il ■ III III III 11
JJJ1!
34
The main factors to be addressed in making real progress against TB fall
in four main categories - organizational, managerial, technical and
developmental. Elements of the present health care system, and many parts of
the current TB control programme provide the basis for implementation of
major improvements. Strengthening and reorientation of policy and program
execution in each of the problem areas offer sound prospects of improvement
in curing TB patients in numbers which will result in 8-10Z annual decline in
the risk of infection and effectively halve the tuberculosis burden in about
a decade while ensuring much lower disease and infection rates for decades
into the future.
The state TB control programs are well structured and have direct
intervention capabilities at the district level and below in about three
quarters of the country. In contrast, the national TB control programme has
languished vich ineffective terms of authority and budgets and an
exceptionally low executive position within the Ministry of Health for such
an important disease. Monitoring, critically examining and adjusting
national policy for effective state performance has consequently atrophied.
In Che absence of a strong central Ministry unit, power for TB policies
has been ceded to the National TB institute (NTI) in Bangalore, The NTI has
had preeainence in training and sone types of research for TB but now suffers
serious institutional weaknesses, Budget shortfalls, unfocussed direction of
research, training progran content which is not replicated at state level and
lack of experience with making and icrplerienting policy have left a gap in
national TB leadership. The absence of a national policy body for TB at
central level, supported by a strong executive TB unit within the Ministry,
has meant that no revision of policy has been made in spite of repeated
evaluation showing poor results, and therefore NTI has not changed or
developed alternative TB Program procedures.
Further, the content of their training has stagnated in relation to
recent TB control success elsewhere. In the absence of a strong central
prograii, NTI has been forced to assune progran managenent and standard
setting functions which are inappropriate for a training/research
institution. This is particularly true as NTI does not have the staff and
executive authority to nonltor and enforce conpllance of the states with
policy.
Below the State level, TB has been indicated as a priority for
integration into the key health services. However, the TB program's
effective cooperation with health service providers at the primary level and
willingnass of the providers, under current policies, to devote substantial
attention to TB, remains doubtful at best. The ambivalence resides both in
lack of strong and focussed national program direction and in the absence of
policies responsive to the legitimate interest at the local level for a
clearcut, standard, easy to follow program which is effective for cure.
Strong direction, some decentralization below the district level, training,
increased funding and a comprehensive policy package are needed.
Technical problems confronting the NTP are both historical and the
result of soma isolation. There remains traditional emphasis on case-finding
activities whan only a minority of discovered cases are being cured.
Technical practices emphasize radiographic methods which are sensitive, but
not specific, rather than concentrating on high-quality microscopy which with
a good quality control system can be both specific and sensitive. Too
frequently, one sputum smear is examined rather than several, leading to
inappropriate treatment of Infectious cases. Microscopes are often monocular
and of poor quality, training is uneven and quality assurance systems seldom
function. Protocols for appropriate use of radiography and clinical
diagnostic methods need to be prepared and disseminated.
4
35
Treatment for diagnosed patients is chosen from too many regimens and
adequate short-course chemotherapy is yet infrequently used and is completed
in only a minority of cases. Repeated sputum smears during the course of
treatment are not regularly taken to monitor effectiveness of therapy.
Provision of services is often too remote or inconvenient to encourage
patient compliance, and providers lack adequate motivation and training for
patient supervision. Improved treatment protocols, training, adequate
supplies of only SCC drugs, and adaptation of practices to provide some
degree of supervised initial chemotherapy, whenever feasible, are needed.
Recording and reporting procedures do not permit rigorous supervision of
the system as a whole or at the institutional level. Case definitions are
not adequate. Criteria for completion of treatment and discharge do not
exist. Laboratory registers and patient treatment registers do not contain
the information necessary to perform cross checking or to monitor the
performance of states, districts, blocks or individuals providers.
Conversion status of smear positive patients cannot be documented. Cohort
analysis to ensure and measure program effectiveness cannot be satisfactorily
done with present registry formats and procedures. Therefore, adaptation of
existing TB Program policies and resources to implement and improve recording
and reporting system is required.
Developmental constraints include both institutional and financial
issues. Operational research to test and improve on program performance is
not currently an integral part of the TB program. Training materials and
objectives are in need of revision to support a revitalized program and
pedagogical content may need improvement. Medical college curricula need
additions to provide both theoretical and practical exposure to the elements
of TB control as doctors graduating now will continue to see TB throughout
their working careers. Present private medical practitioners need to be
educated about modern treatment and policies of the program. This can be
done through existing NGOs. To do this, strengthening of the NTI, of the
state level training centre, and studies and technical assistance at both the
national and state levels will be needed. Opportunities for overseas
training and experience will accelerate adoption of effective new experience
in TB control elsewhere.
The government has recently decided to increase funding for TB control
and is for now continuing to provide for the treataent of all TB patients
1 in the public systea.» The present high number of overdiagnosis and
diagnosed
treatment of patients which now appears to be occurring offer scope for
savings in an improved program. Overall though, financial resources for TB
appear to have declined in real terms in recent years because of Inflation
and rising import costs, despite the government's recognition of the trend
and efforts to counteract it. Moreover, only a fraction of patients today
requiring treatment receive it in full.
A strengthened program will require increased resource allocations at
both the central and local levels for drugs, supervision (including
transport), training and operating cost. Given the demonstrated cost
effectiveness of TB control programs compared to other health sector
wich external
external
Interventions, revision and expansion of India's TB program with
financial assistance would appear to be fully justified.
7
hi
Pi
r
111 I
Ml III IIMMII
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i_-OL_p
I
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iJSV
36
0
12, RECOMMENDATIONS
1.
The structure of the National Tuberculosis Programme should be
strengthened by 1) establishing an apex policy making authority and an
executive task force with managerial functions to implement programme
reorganization, and 2) upgrading the central tuberculosis control unit
in the Directorate to provide strong leadership and enhance the
efficiency and effectiveness of the National Tuberculosis Programme
2.
The quality of patient diagnosis should be improved by 1) using three
smear examinations to detect infectious cases among symptomatica before
deciding on patient treatment, 2) ensuring the quality of microscopy
with adequate equipment, training and quality control, and
3) establishing criteria for diagnosis by radiological and clinical
methods.
3.
National and state tuberculosis programme resources should be directed
to ensuring cure of tuberculosis patients, giving priority to infectious
cases of tuberculosis by 1) adopting short-course chemotherapy, 2)
establishing criteria for treatment completion, cure and discharge from
medical care, and 3) ensuring an uninterrupted supply of drugs of good
quality.
4.
The current NTP system of registration and notification should be
revised to emphasize the cohort analysis of treatment results
(completion and cure, transfers, defaulters, died, treatment failures)
as the main indicator of prorraTime effectiveness.
5.
Policies should be developed to ensure decentralization of treatment
services closer to the community level to enhance access to care and
patient compliance to recommended therapies.
6.
Pilot projects should be implemented at block level to test the
feasibility and results of different technical and organizational
strategies to be adopted by the tuberculosis programme -- i.c., to test
the capacity to implement recommendations 2-5 above.
7.
A medical officer or treatment organizer and a laboratory supervisor,
with the necessary transport, should be added to the existing
administrative structure at the sub-district level (about 500,000
population) to strengthen tuberculosis programme management and to
facilitate decentralization of supervision.
8.
Training materials must be developed to reflect the proposed changes in
programme policies and procedures. The current training infrastructure
will need to broaden the scope of its training capabilities by utilizing
state training facilities, medical colleges, public health .institutes
and tuberculosis-oriented voluntary agencies to augment training
efforts. International and national training opportunities should be
made available for the different levels of tuberculosis programme staff.
9.
Operational research must be carried out as an integral part of the
revised tuberculosis programme to evaluate programme performance,
improve delivery of services, problem solving and obtain baseline
epidemiological information to measure reduction in the risk of
infection.
37
ANNEX 1
PARTICIPANTS IN THE COMPREHENSIVE PROGRAMME REVIEW NATIONAL TB PROGRAMME
INDIA 1992
1. Dr C.M. Agarwal
Deputy Assistant Director General (EPI)
Ministry of Health and F.W. Nirman Bhavan
New Delhi
15/ Dr F. Luclmo
Medical Officer
WHO/HQ/Gcnevi
(1) Dr J. Anderson
WHO/SEDA Consultant
Sweden
16. Dr Manjula Dana
TB Research Centre
Spurtank Road, Chetput, Madras
Dr R. Balambal
TB Research Centre
Sputrank Road, Chetput, Madras
17. Mr N.G.K. Nair
Statistician
Institute for Research in Medical Statistics
Madras
4. Dr Shibani Bandopadhyay
Assistant Director (EPED)
NICD, Delhi 110054
i 18. Dr A-SJ-. Narayana
Statistician
Tuberculosis Research Centre, Madras
5. Dr B.N. Bardadary
Deputy Director General (G)
Ministry of Health and Welfare
Nirman Bhavan, New Delhi
j 19. Dr Paramavisam
TB Research Centre
Spurtank Road, Chetput, Madras
6. Dr S.V. Bhakta
State TB Officer
9, Institutional Area, Lodhi Road
New Delhi 110003
20. Mrs R. Pray RN, MS.
“ Consultant
IUATLD
7. Dr P. Chandrasekhar
Former Epidemiologist
National Tuberculosis Institute
Bangalore
21. Dr S. Radhakruhna
Director
Imntute for Research in Medical Statistics
Madra*
’8/ Mr Chandrasekaran
Statistician
Tuberculous Research Centre, Madra*
22. Mr C.V. Shyamaiundara
Ex-Scati*tician
National Tuberculocii Institute, Bangalore
23. Dr CP. Singh
Consultant
Dr Ram Maanohar Lohia Hospital, New Delhi
Dr M. Felten
Medical Officer
WHO/HQ/Genova
@ Dr MJ. George
WHO National Programme Officer
Office of the WHO Representative India
IRC Buildmg, Now Delhi
.>£
-.rJ .•
11. Dr Govind* Prasad
Director, Now Delhi TB Centre
JJ- Nehru Marg, New Delhi 110002
12. Dr R.C. Jain
Director
LRS Institute of TB and Allied Diseaiet
Aurobindo Marj, New Delhi 110030
15. Dr Kumaraawamy
TB Reaearch Centre
Spurtank Road, Chetput, Madra*
14. Dr A.G. Kurthkod
Senior Medical Officer
Central Government Health Service*
Bangalore
24. Dr S. Spinaci
^-^Medical Officer
WHO /HQ/Geneva
<25. Dr P. Sudre
v Medical Officer
WHO/HQ/Geneva
Dr Umapathy
TB Research Centre
Spurtank Road, Chetput, Madras
(27) Dr J. Veen
WHO Consultant
The Netherlands
A?o Ai" 1
■ I
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<-
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-
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38
ANNEX 2
INSTITUTIONS VISITED AND PERSONS INTERVIEWED
CENTRAL LEVEL
INSTITUTION
MAIN PERSONS INTEKVIEWED
-TB Association of India
Dr D.R. Nagpaul
Vice President and Hon. Technical
Adviser. TAI, New Delhi
SXSlX cA (.id | Lc-o—
Dr S.P. Pamra
Former Hon. Technical Adviser
TAI, New Delhi
-Ministry of Health
Dr P. Kumar
I/C ADG TB, Nirman Bhavan, New Delhi
-Planning Commission
Prof. I.C. Tiwary
Adviser (Health), Planning Commission
New Delhi
-National Malaria Eradication
Programme
Dr NarasImham, Director NMEP, New Delhi
-Universal Immunization Programme
Dr (Miss) Jotsna Sokhey
Dep. Commissioner (MCH), Nirman Bhavan
New Delhi
-Medical Stores Department
Dr Biswas, Medical Stores Division
R.K. Purman, New Delhi
-Central Health Education Bureau
Dr Hiramani,
CHEB, Kotla Road, New Delhi
-National Institute of
Communicable Diseases
Dr T. Verghese
Director, New Delhi
Dr R.C. Sharma
Epidemiologist, NICD, New Delhi
LRS TB Hospital, Aurobindo Marg
New Delhi
Dr R.C. Jain
Medical Superintendent, LRS TBHospital,
New Delhi
-New Delhi TB Centre
J.L. Nehru Marg, New Delhi
Dr Govind Prasad
Director, NDTB Centre, New Delhi
-National Aids Control Org.
Red Cross Road, New Delhi
Dr L. Khodakevich
Medical Officer, Global Progr. on AIDS
WHO, India
-National Task Force on Malaria
Dr Harcharan Singh, Chairman
(Former Adviser, Planning Commission)
-Indian Council of Medical Research (ICMR)
Dr S.P. Tripathy, Director General
39
TAMIL NADU STATE
MADRAS
INSTITUTION
KAIN PERSONS INTERVIEWED
-Ministry of Health
Mr K. Inbasagaran
Health Secretary
-Anti-TB Association of
Tamil Nadu
Dr Suslla Raj
Director of Medical Services
I/C and Vice Chairman
-Institute of Thoracic
Medical Association
Dr Panchamurthy
President of the Madras City
I.M.A. etc.
-Central Medical Store
-Government TB Sanitorium
Thambaram
Dr R. Paramasivam
Superintendent
-Institute of Public Health
Poonamallee
Dr A. Rama1Ingaswara Rao
Director of Public Health
Dr Prithivi, Director
Dr A. Subramanian (STO)
-State Tuberculosis Division
-Medical and Health Services
Dr Bhaktavalsalan
-Indian Medical Association
SALEM
-DTC Salem
Dr T. Arunagiri (DTO)
PHI - Nainampatti and subcentre
PHI - Karipatti and subcentre
PHC - Vzhapadi (RC)
CH - Athur (XC)
PHC - Vlnaitheerthapuram and subcentre
GH - Raslpuram (XC)
PHI - Sengalandapuram (RC)
GH - Omalur (MC) Leprosy Centre
Relief Rural Centre - Chettipatti
PHI - Sarkapalliyur (MC)
PHI - Slrkar Kollapatti (RC)
GH - Mattur Dam
THANJAVQOR
-DTC Thanjavoor
Dr Mohan Raj -DTO
Dr G. GovindarajaluDeputy Director Medical Services
Dr R. Elango
Deputy Director Health Services
-Indian Medical Association
Thanjavoor District
Prof. V. Thiyagarajan, President
T.M. Thanjavoor
I-
40
■
-District Collectors Office
PHI - Nadu Cauvery and Sub-centre
PHI - Budalur and Sub-centre
PHI - Vallam and Sub-centre
PHI - Melattur (XC)
Panchayat Union Dispensary - Sengipattl (RC)
Panchayat Union Dispensary - Vaduvoor (RC)
GH - Mannargudi (XC)
CH - Thiruvaiyary (RC)
GH - Kumbakonam (XC)
GUJmT STATE
-Ministry of Health
Mr Bhanuj an
Health Secretary
Mr Sugathan
Commissioner, Health
Dr N.G. Ghasura
Addl. Director , Health Services
-State Tuberculosis Division
Dr B.M. Soni
State Tuberculosis Programme Officer
-State Tuberculosis Demonstration
and Training Centre
Dr P.P. Mehta
Director
-State Tuberculosis Association
Dr Patel
Chairman
-Indian Medical Association
Gujarat State Branch
Dr I.C. Shah
BHAVNAGAR
-K.J. Mehta TB Hospital
Amargadh - Bhavnagar
Dr M.D. Gandhi
Medical Superintendent
-District Medical Office
-Government Medical College
-District Tuberculosis Centre
Community Health Centre (XC)
Mandvi • Surat
PHI - Kathor (MC) and Sub-centre
Civil dispensary Gadat - Surat (RC)
Dr Shah (DTO)
41
UTTAR PRADESH STATE
LUCKNOW
-Ministry of Health and
Family Welfare
Mrs Sunita Khandpal
Principal Secretary
-Ministry of Health and
Family Welfare
Dr Bacchilal
Additional Secretary
-Department of Health
Dr P.D.P. Mathur
Director General, Health Services
-Department of Health
Dr B.N. Saxena
Director General, Health Services
-Department of Health
Dr P.K. Tandon
Director National Health Program
-Department of Health
Dr Brljendr* Singh, JD (TB)
-Department of Health
Dr J.K. Agarwal (CMOH)
-ThakurganJ TB Hospital
Dr Saxena (CMOH)
-RFPTC - Indira Nagar
Dr V. Kumar, Epidemiologist
-Kanpur General Medical College
Dr Sharma, Acting Principal and
Professor of Paediatrics
-Kanpur General Medical College
Dr M.S. Agnihotri
Professor of TB and Chest Diseases
-Uttar Pradesh TB Association
Dr Sinha
President
VARANASI
Dr Gyanendra Singh, DTO
-District Tuberculosis Centre
AGRA
-State Tuberculosis Demonstration
Training Centro
Dr V.K. Tewary
Director and Professor
-State Tuberculosis Centre
Dr M.L. Mehrotra
Ex - Director
Dr Gupta, CMOH
Dr K.D. Gautam, Statistician
KANPUR
-District Medical/Health Services
Dr Ram Babu, CMOH
-District Tuberculosis Centre
Dr S. Nath, DTO
-General Practitioner
Dr Singh
-Kanpur Medical College
ML Chest Hospital
Dr Katiyar
Professor of TB
fSO oto tA Cm fKJ "TP" (Acx i
K
42
ANNEX 3.1
BACKGROUND information
The National Tuberculosis Program (NT?) of India must be viewed within
the context of India's political and socio-economic profile.
2^,,
India is the secondjargest country in the world and contains nearly_a_
fifth of the world's population. The present population is derived from six
main ethnic groups, dispersed unevenly between urban and rural areas, with
roughly 75X of'~the population residing in rural regions of India. Crude birth
rates, death rates and infant mortality rates are higher in the rural parts
of the country. Thirty seven percent of India's ruralpopulation is below the
country's poverty line, consisting largely of the landless, marginal^and
small farmers and other marginal workers. Although great strides have been
made in the universalization of primary education in recent years, adult
literacy rates remain low because of lack of universal free availability of
formal education in the previous decades.
India has experienced clear periods of economic growth, evidenced by a
rising gross domestic product, gains in per capita Income, and growth in
agriculture, industry and in consumer goods production. The economic gains
are however unevenly distributed within the country, despite welfare schemes
implemented to alleviate poverty and unemployment. Steady gains in per capita
income and gross national product have been offset by poor balance of
payments and inflation.
A network of air services, railway system, and roads provide linkages for
the vast populations of India. A spreading network of telecomnuxilca,tions_
facilities complement the transportation systems, facilitating within country
business transactions and implementation of health and family welfare
programmes.
After gaining independence in 1947, India has become a multi-party
democracy, with. a._federal structure reflected in both the central and state
governments. Local self governments are in place in cities (municipalities)
and in villages in the form of panchyat raj institutions. A strong
bureaucracy lends continuity and stability to gubernatorial administrations
throughout the country.
43
HEALTH SECTOR
Principal health problems:
Morbidity statistics with regard to the Incidence and prevalence of
diseases are not available for the country as a whole. The main sources of
such statistics are health care institutions , community surveys, and ad-hoc
studies conducted on specific subjects. 1986 data depicting the five leading
causes of deaths due to major communicable diseases in descending incidence
are as follows: n^xculasls, tetanus, viral encephalitis, viral hepatitis,
and meningococcal influenza. 1986 morbidity data in descending incidence are
as follows: influenza, tuberculosis, enteric fever, whooping cough and viral
hepatitis (11). Data on causes of death in all major cause groups lists
asthma and bronchitis, clubbed together, as the leading cause of death,
followed by tuberculosis, pneumonia, cardiovascular disease, and anemia.
j
Age-specific morbidity and mortality data Indicate that the major causes
of morbidity and mortality among children in India are Infectious and
parasitic diseases, and diseases of the respiratory system. Among adults,
Infectious and parasitic diseases are Joined by diseases of the circulatory
system, Injuries, and poisonings as major causes of morbidity and mortality.
Health policy and strategy:
The government of India has entrusted a specialized body, viz., the
Planning Conmission, the responsibility to be the Advisory Body for health
care policy formulation, functioning at the highest policy level without,
however, being involved in the responsibilities of day-to-day administratioh.
r'JOCC‘'cu
The Planning Commission*s current Five Year Plan on the nationa1 health
policy of the India government emphasizes political as well as administrative
commitment to ’Health for All by the Year 2000’ enunciated in the Alma Ata
Declaration of 1978 The policy places emphasis on developing a rural health
care system based on a combination of promotive, preventive, and curative
health care services taking the village as a base, and de-emphasizing
hospitals, super•specialities, and highly trained doctors practicing mainly
in urban areas.
A large Increase in the population of India as evidenced by the 1981
country-wide census is attributed to a fall in the death rate brought about
by significant improvements in health conditions, effective control of
epidemics and overall socio-economic development over the last three decades.
The control and stabilization of population growth is considered essential in
order to maximize gains in the socio-economic and health sectors.
Thus, national health policy demographic targets are aimed at achieving a
net reproduction rate of one (NRR:1) by the year 2000 AD, with a crude birth
rate of 21 per thousand and a crude death rate of 9 per thousand. The
intention is to bring the population growth rate down to 1.2 per annum from
the growth rate of 2.5 per annum recorded during the decade 1971-1981. The
policy also stresses the need for closfc linkages at the primary level between
health and family welfare programmes including MCH. It further lays down the
Infant Mortality Rate of below 87 by 1990, and of 60 or less by 2000 AD from
the 1980 level of 114 per 1,000. At present, the IMR is 96. Nutrition and
immunization are considered essential to bring down the IMR. Children up to
one year of age under the Expanded Programme of Immunization are targeted for
vaccine coverage as well
as prophylaxis against anaemia and vitamin
we
The targets for ’Health for All by the Year 2000'include a statement on
tuberculosis. Levels (percentages) of tuberculosis cases completing
treatment out of those detected have been set for the years 1983, 1985, 1990,
and 2000. Current data indicate that tuberculosis cases completing treatment
are 25 percentage points behind projected figures.
4
44
Health services and structure:
A parallel structure of politlcal/administrative and technical advisors
is in place at both the federal and state level of government to implement
the country’s general health services.
At the Central level, there is aJ<lnls,try_CLt_H_e-alch and Family Velfare
consisting of two Departments^ namely the Department of Health and the .
Department of Family Welfare. Both departments are headed by the Secretary to
the Government The Secretariat functions under the direction, control and
supervision of the Cabinet Minister who is usually assisted by the Minister
of State. The Directorate General of Health Services serves as the technical
wing to the Ministry and its activities cover the whole spectrum of medical
care and public health apart from general administration.
Most health programs, with the exception of leprosy and family welfare,
are_jntegrated at the district level where a district medical
officer/district health officer organizes the planning, implementation, and
supervision of different health programmes, using a network of primary health
institutions and multipurpdse^healtH workers.
Strides have been made to Increase the numbers of health care personnel.
Presently, there are 108 recognized medical colleges and 17 unrecognized
medical colleges with an annual admission of 11,562 and out-turn of
'approximately 11,000 graduates. A majority of these institutions have
facilities for post-graduate education, producing approximately 6,000 post
graduates annually.
In 1946{ there were only 7,000 nurses in Indja, each serving a population
of 43,000. It was recommended that there should be one nurse for every 500
of population. Facilities for training nurses were implemented, resulting in
a net out-turn of 8208 nurses in 1986, up from 1282 in 1950. Currently the
nurse to population ratio ranges from 1:1179 in urban areas to 1:6075 in
rural areas.
The supply of pharmacists was extremely meager in 1951. There were only
two institutions offering degrees in pharmacy? in the country with an annual f
intake capacity of 70 and an out-turn of 38.< It has increased to 12
institutions with an intake of 675 and an out-turn of 281 by 1961. No
information with regard to total number of pharmacists registered with the
Council are available.
There 1* * greet vitiation In the distribution of health manpower e.g.
the doctor population ratio varies from 1:820 to 1:1560, with demand greatly
exceeding supply In rural areas. Reorientation of all categories of health
care providers towards primary health care at the community level has helped
to ease the demand at the periphery. In addition, the national health policy
has established a goal of having one male and one female multipurpose worker
for every 5000 rural population. Plans to convert existing unipurpose
workers and Integration of organization and structure of various health and
f1y welfare programmes at the primary health centers are well under way.
Health budget:
The current budget for health and faaily welfare (Seventh Plan 1985-1990)
is 66 489 million Rs, roughly 1.9X of the total budget is for health and
81
for family welfare. During 1988-89*there has been a great emphasis on ru
health and control of communicable diseases, reflected in funding to
program.*, for the eradication of malaria, leprosy, and tuberculosis.
n-
.5^
. A*
POPUIATION OF INDIA FROM 1901-1991
CENSUS
YEAR
POPULATION
IN MILLION
SEX RATIO
F
M
1901
238
0.972
77
11
1911
252
0.964
82
10.3
1921
251
0.955
81
11.2
1931
278
0.950
90
12
+ 11
1941
318
0.945
103
3.9
+ 14
1951
361
0.946
117
17.3
+ 13
1961
439
0.941
142
17
+ 21.5
1971
548
0.930
177
19.9
+ 25
1981
685
0.933
216
23
+ 25
1991
840
0.929
256
27.5
+ 23.5
POPULATION
DENSITY
NO./SQ.KM
URBAN
DECADAL
POPULATIONGROWTH
X AGE
RATE
+
5.7
0.3
The different population health indices are listed below for the last 10
years.
CENSUS
YEAR
RATE
CRUDE CRUDE GROWTH
BIRTH DEATH RATE
RATE
GROSS INFANT
FERTI MORTAL.
RATE
LIFE EXPECTANCY
AT BIRTH RATE
MALES FEMALES
1981
33
12
21
156
110
55.6
56.4
1986
29.7
10.7
19
136
92
58
59
1991
26.7
9.3
17.4
118
80
60.6 ' 61.7
LITERACY RATES (PERCENT)
CENSUS YEAR
MALE
FEMALE
1901
1911
1921
1931
1941
1951
1961
1971
1981
1991
9.8
10.6
12.2
15.6
24.9
25.0
34.4
39.5
6.7
63.9
0.6
1.0
1.8
2.9
7.3
7.9
12.9
18.7
24.9
39.4
TOTAL LITERACY
5.4
5.9
7.2
9.5
16.1
16.7
24.0
29.5
36.2
52.1
• I
A6
ENROLLMENT IN SCHOOLS (PERCENTAGE)
CENSUS
YEARS
MIDDLE SCHOOLS
PRIMARY SCHOOLS
(11-14 YEARS)
(6-10 YEARS)
GIRLS TOTAL
GIRLS TOTAL BOYS
BOYS
1950-51
61
25
43
21
5
13
1960-61
83
41
62
33
11
23
1970-71
93
59
76
46
21
34
1980-81-
99
66
83
52
27
40
1985-86
109
77
93
65
38
52
EDUCATIONAL INSTITUTIONS 1987-88
PRIMARY SCHOOLS
543 677
MIDDLE SCHOOLS
141 000
SECONDARY SCHOOLS
71 300
COLLEGES FOR GENERAL
EDUCATION
4 329
PROFESSIONAL EDUCATION :
876
UNIVERSITIES AND CENTRES FOR
HIGHER LEARNING
190
47
J
GNP TRENDS
INDIA 1987-88
GNP
(IN 1000 MILLIONS
AT CURRENT PRICES)
YEARS
PER CAPITA NET
NATIONAL PRODUCT
1950-51
91
254
1955-56
97
236
1960-61
140
306
1965-66
219
426
1970-71
365
633
1795-76
664
1026
1980-81
1226
1627
1985-86
2326
2734
1987-88
2915
3284
CATEGORY OF PERSONNEL
PRESENT ANNUAL
NUMBER TRAINED
TOTAL NUMBER
(1987)
1. Doctors
a.
Under-graduates
12 000)
b.
Post-graduates
5 000)
330 000
850
9 800
3. Nurses
10 000
245 000
4. Auxiliary-Nurse Mid wives
15 500
132 000
660
16 000
2. Dentists
5. Health visitors
6. Laboratory technician
7. X-Ray technicians
2 200
800
8. Pharmacists
12 000
9. Multi pupose workers
8 200
182 000
NA
NA
10. Medical Statisticians,
Statistical Assistants,
and Medical Record Clerks
_!_L
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STATE TUBERCULOSIS OFFICER
CHIEF MEDICAL OFFICER OF HEALTH
ASSISTANT DISTRICT MEDICAL OFFICER OF HEALTH
DISTRICT TUBERCULOSIS OFFICER
MEDICAL OFFICER
MEDICAL SERVICES
FAMILY WELFARE
51
ANNEX 4.1
PRESENT TREATMENT PRACTICES
1. Case definitions
To report the regimens most commonly used in the NTP, patients are
categorized according to the site of the disease (pulmonary or .
extrapulmonary), bacteriological status and history of previous tuberculosis
treatment (see WHO Guidelines for Treatment of Tuberculosis in the National
Tuberculosis Programmes).
1.1 Definitions according to the site of the disease.
Pulmonary smear-Ptficive patients are those reporting one of the following
cardinal symptoms: cough for two weeks or more, chest pain for one or more
months, hemoptysis. They should be proved smear-positive by at least one
sputum smear examination (10 bacilli or more seen in one hundred fields).
PulmonflTY smeflr*nepatients are those with the cardinal chest symptoms
with an x-ray of the chest suggestive of tuberculosis and smear-negative on
two consecutive collections (usually one on the spot and one early morning).
Patients with pleural effusion are categorized as smear-negative.
Extratulmonary tuberculosis is tuberculosis of an extrapulmonary site
diagnosed on clinical basis by a medical officer.
1.2 Definitions according to previous history of tuberculosis therapy.
Nev patientg are those not indexed in the District Tuberculosis Centre (DTC)
and not previously treated in the DTC. Patients previously treated or under
treatment by an institution not reporting to the DTC are considered new.
Old patients are patients:
receiving treatment in the DTC
resuming treatment after being lost
previously indexed in the DTC, have completed the prescribed regimen
and are smear-negative at the end of chemotherapy, and they come back
to the DTC with symptoms suggestive of tuberculosis (relapses). A
relapse patient can be smear-positive or smear-negative.
patients smear-positive after having completed the prescribed regimen
(failures of a treatment for new patients and chronics)
not attending the DTC for two or more months (lost)
2.1 Reginens for new patients:
Pulmonary smear-positive
conventional chemotherapy
(1) 2SEH/10EH
(2) 2STH/10TH
Patients clinically not improved at the end of the 12 months period
receive 6 more months of EH or TH.
05829
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>z
- Short course regimens
(1) 2HR2/6EH
(2) 2HR2/6TH
(3) in sanatoria and chest hospitals: 2 EHRZ/^HR
and hilar adenopathy):
Pulmonary smear -negative (including pleurisy
- conventional chemotherapy
(1) ZSjHx/lOEH
(2) 12EH or 12TH
(3) Ln sanatoria and chest hospitals: 3STH/12TH
at the end of the 12 months period
Patients clinically not improved
receive 6 more months of EH or TH.
miliary tuberculosis)
Short course regimens (for cavitary or
(1) 2HRZ/6EH
(2) 2HRZ/6TH
(3) in sanatoria and chest hospitals: 2HRZ/4HR
Tuberculosis in children (0-5 years old)
Pulmonary forms: 12 HR (HE)
Extrapulmonary forms: 18 -24 HR (HE)
abdomen:
Extrapulmonary tuberculosis of lymph nodes, bones.
(1) 2STH/10TH
(2) 12 EH (TH)
(3) 2SEH/10EH
seriously ill:
Meningitis and other extrapulmonary patients
(1) 2HESRZ/6HR
2.2 Old patients:
Relapse and failure (all forms)
(1) in sanatoria: 2STH/18TH
(2) in DTC: 3STH/18TH
Chronics: TH lifelong
.
to which the patient is still sensitive.
are referred to
—i and appropriate
treatment according to the
prescribed
53
■ .J
ANNEX 4.2
GUIDELINES FOR TREATMENT ORGANIZATION
Correct treatment should Include the following:
Patients should be provided a standardized regimen according to the
type of disease and treatment history
All pulmonary smear-positive patients detected in the district should
be monitored by sputum smear examination during chemotherapy and at
the end of chemotherapy
It should be ensured that pulmonary smear-positive patients are cured
(that they complete drugs collection and remain smear-negative until
the end of the prescribed regiuen)
It is essential to prepare a new national policy and structural reform
package and a workplan for the new programme Implementation, starting in
States in which there is a sufficient political commitment for improving the
tuberculosis programme. Reliance on "conventional" chemotherapy is
inadvisable because the cost of these regimens is approaching the cost of
short course regimens (SCC) when ethamburol is used instead of thiacetazone.
(The cost of ethambutol is approximately four times higher than that of
thiacetazone and one dose of streptomycin costs approximately 2/3 of a daily
dose of rifampicin). Simplified guidelines should be prepared for the
prescription of appropriate regimens. It is advisable to recommend one
regimen per category of tuberculosis patients, with few alternatives to adapt
them to State specific situations. SCC regimens are the most cost-effective
regardless of patient categories. Guidelines for case management of all
forms of tuberculosis, linked to the resources made available for purchasing
drugs, should be provided.
Priority for SCC should be given to new pulmonary smear-positive cases.
Such cases should be identified by a proper treatment history taken by a
medical officer, with clear guidelines on how to collect the information.
During the interview, the patient should perceive that the type of drugs that
he will receive will not depend on his answers. It should be emphasized that
a smear-positive case of tuberculosis that becomes negative during the
initial phase of treatment usually has a little chance of becoming smearpositive again during the continuation phase of chemotherapy. Cases that
remain smear-negative are practically at no risk of developing acquired drug
resistance.
Smear-positive relapses should be identified as the second priority
category. These patients should be identified by a careful treatment history.
Guidelines should specify key questions to differentiate "true" relapses from
failure cases that have previously taken irregular chemotherapy. Such
irregular smear-positive failure cases should have the lowest priority among
smear-positive cases due to high risk of having already developed acquired
drug resistance to the most potent anti-tuberculosis drugs (isoniazid and
rifampicin). Treatment of failures should not divert resources from
effective treatment of new smear-positive cases and smear-positive relapses.
Pulmonary smear-negative patients who are severely ill (with cavitary or
miliary tuberculosis) and severe extrapulmonary cases should have the same
regimen as the new pulmonary smear-positive cases. Tuberculosis meningitis
cases require a regimen with the same initial phase as new smear-positive
cases, with a continuation phase containing rifampicin and isoniazid for 6
months. Pulmonary smear-negative and extrapulmonary patients not included in
the previous category (as lymphadenitis, pleurisy, childhood tuberculosis)
may be offered different regimens.
■I
IIMMI I III Illi Illi
ill
■■■■ II
5-4
Indicators of patient adherence co the prescribed regimen must be
specified. The guidelines should emphasize the importance of assessing smear
conversion after 2 months of che initial intensive phase for new smear
positive patients on SCC. Patients who are still smear positive after 2
months of therapy should continue the same combination of drugs for an extra
month. Re-motivation of these patients is an essential component of their
therapy. Smear-positive patients should be considered cured only after
confirmation of sputum smear negativity in order to make available the data
to monitor the cure rate among all new smear-positive cases diagnosed.
Pulmonary smear-negative and extrapulmonary cases may be discharged after
completion of the prescribed number of monthly drug collections.
Patients who are smear-positive before chemotherapy should be rigorously
educated about the Importance of sputum examination during the follow-up of
chemotherapy. Responsibllity for ensuring the regularity of drug pick-up
during the initial phase of the regimen for these smear-positive cases should
be given to the staff of PHIs and subcentres. Supervisors should assess if
the target of SOX smear conversion after 2 months of SCC chemotherapy and
more than 90X at three months, among patients that started chemotherapy 3 to
6 months before, has been achieved. If the target is not achieved, full
patient supervision should be considered.
New sne&r-positive patients unable to attend ambulatory therapy (because
they are too sick to walk or are living in a place unsuitable for fully
supervised treatment) should be hospitalized for 1 to 2 months in the nearest
TB hospital.
Guidelines for accomplishing tuberculosis programme activities should (1)
aim to improve the supervisory capacity of DTC, (2) encourage patient's
diagnosis and treatment at PHI level, (3) assign to the staff at block level
clear responsibilities for ensuring patient treatment and follow-up. Their
main target should be the achievement of high smear conversion for new smearpositive cases at the end of the initial phase of SCC (SOX at two months and
90X at three months) and a high cure rate (in the first two years of the
programme more than 70 X and then 85X among new smear-positive cases).
TB sanatoria and hospitals should be more involved in the DTP and their
activity should be focused to achieve the same objectives as the PHI at block
level. Policies for the use of hospital beds should give priority to ensure
smear conversion among new infectious cases and failure cases.
At state level districts with the best performing staff and in a
logistically favorable position for frequent supervisory visits should be
selected to implement the new programme. The number of districts to be
involved and the plan for expansion should be proposed by the state TB Office
and revised by the national TB Unit. In each district only the best
performing PHIs should be initially Involved and frequently supervised by the
DTC staff. The implementation of the plan should ensure that no lack in drug
stocks will occur. The expansion of the programme in the district should be
rapid enough to avoid the fact that patients from blocks not included in
programme will be attracted to the implementing PHIs. The expansion should
be based on smear conversion rates achieved among the total number of new
smear positive patients and smear positive relapses diagnosed and put on
treatment.
Training courses for HOs working in the DTC and in the PHIs Involved in
the programme should be planned and the training programme approved by the
national TB Unit. Retraining of the microscopist and provision of binocular
microscopes should be a requisite for implementing the districtprogramme.
The following guidelines for programme management at district level
should be issued by the NTP and approved by each state before extra resources
for progranma implementation are allocated to the programme.
4 '<
55
A. Guidelines for patient and programme management, including:
1. Casa-definitions and regimens
2. Frequency of patient's follow-up by smear examination
3. Methods for ensuring patient adherence to the prescribed regimen
4. New recording and reporting forms and registers
5. Programme evaluation methods
6. Drugs procurement and stock
B. Guidelines for preparing a workplan for the implementation of the new
district tuberculosis programme.
«
56
ANNEX 5.1
COORDINATION WITH OTHER PROGRAMMES
AIDS Control Programme
1991 estimates show India as having at least 750,000 HIV Infected
■ j from 0.1X in Calcutta
individuals. Studies of prevalence show rates varying
1
has
an
active
health education arm
to 1% in Bombay. The National programme I— well
as
high
risk
targets
e.g.
aimed at the population at large as ’--prostitutes.
^^jSSM.5Su:S!.r«AS--
country. At present,
/'mafnlv at medical colleges and universities)
centers have been established
X
mnrrol efforts
The programme
order to protect blood donations.
Tn lleht of a growing awareness of the importance of tuberculosis
....
" wo-
made by AIDS programmm. personnel to includ.
tub r u
AIDS programme at both the central and stat, levels of
:Xku"S”M’
"
delivery.
pronoelon of pr.v.ntlv. eh-orh.r.py .ft.—
for HIV individuals infected with tuberculosis.
Expanded Programme on Immunization
KI i.
Of th. ...t to.t-.ff.otlv. P^lt^lth Pt°S1. ."
The
.
coverage is being extended 1
P
achieve the set targets.. The
- • -,re
i delivery
i™u.^n2i.^1c«n<‘0.\«vi:.d througs^i::ln8 h“lch
'
is
-h'
■“ ’ ■* i in hospitals, dispensaries
and the primary health centres 1.. ~"1
programme is
<- in place
nlace at all Districts in India.
• r of the EPI
of ohlldfn with BCC b.c-. .
and monitors
”h.nt?.l S. Th. ptoStT. porch.... BCG vaccine produced
Madras,
locally by the BCG Vaccine Laboratory at Madras,
■"
Th.
Leprosy Programme
The leprosy programme of I"dla
i:d«X\b.^on:hM^ctnZL
The programme
* {‘‘j^entrllized’to sub-center
•—: levels,
-t 20,000
successful in
In the country. As
e from
prevslenc
»
/
57
,
t ''“i^
strategies for case detection andPtreatfflentC°:n’? ^rug theyPy- 2> stringent
and 4) active case finding activities.
’ ) lntenalv« health education,
to augment tuberculosis activities at th. community level
'I
4
Pr°’y Perso™el
58
ANNEX 5.2
VOLUNTARY HEALTH ORGANIZATIONS
In India, health care services can be divided into two distinct
components, the public sector or government sector of health care and the
private sector. The private sector can further be classified into a
commercial sector and a voluntary sector. The voluntary sector encompasses
hospitals and health care institutions registered as non-profit societies.
They are operated primarily by Churches and other charitable trusts and
4 associations.
An important voluntary organization in India is the Voluntary Health
Association of India (VHAI). The organization provides for nursing education
with emphasis towards rural and primary health care, rural community health
education, and promotes people's participation in health care. Voluntary
organizations specific to tuberculosis include a tuberculosis sanatorium
opened in 1907 by missionaries at Bhowali and the Union Mission Tuberculosis
Sanatorium started in 1911 by Dr Frimodt-Moller at Madanapalle.
In 1934, with the active support of the Indian Government, the
Tuberculosis Association of India was created to coordinate curative services
as well as train doctors and para-medical workers in tuberculosis work.
Currently, the Association has placed its emphasis on 1) providing health
education to the general public, 2) channeling funds to persons and
institutions for research opportunities, 3) coalition-building of tangential
voluntary organizations to provide a united effort towards the elimination of
tuberculosis, and 4) augmenting government tuberculosis control efforts with
voluntary support e.g. providing alternative hours TB clinics to Increase
access to health care services and providing incentives to health care staff
involved with case-holding activities. TB seal fund raising activities
continue to be a major focus of the Association. Members and executives of
the TB associations tend to be officials of the Health department, either in
active service or retired. Administratively, this membership structure can
facilitate tuberculosis programmme delivery by sharing close collaboration
with governmental efforts and augmentation in areas of need.
I
State anti-tuberculosis associations are actively involved in
tuberculosis activities at the State and District level. The associations
derive funding from the sale of TB Seals and from interest earned on
investment capital. They fund operational research activities, provide
facility construction and maintenance, augment anti-tb drug supplies to
districts experiencing shortfalls, are actively involved in the training of
health care personnel Involved with tuberculosis control efforts, and provide
monetary Incentives to patients on anti-tb chemotherapy. Health education
activities aimed at the general public are also underway. The associations
appear to have great flexibility in their financial expenditures.
The director of the Association is also the State tuberculosis officer.
This dual role may be perceived as an asset in terms of coordination of
•' efforts between a voluntary organization and a government
tuberculosis
programme. The Association has the infrastructure in place and a philosophy
in line with the overall goals of current tuberculosis control efforts that
can facilitate future collaborative ventures.
The Swedish International Development Agency (SIDA) has been providing
assistance for the National Tuberculosis Control Programme since 1979. SIDA
supplies funds for equipment (x-ray units, film), antl-tuberculosls drugs
(Rifampicin and Pyrazinamlde) and other needs to the programme In accordance
with an agreement signed Jointly by the Government of India and SIDA in 1985.
*
59
*2
AKKEX t.1
EPIDEMIOLOGY REFERENCES
1.
Tuberculosis Research Centre.
1989. ICRM, New Delhi.
2.
Tuberculosis Research Cent. e .
1990. ICRM, New Delhi.
3.
Tuberculosis Research Centre.
1991. ICRM, New Delhi.
r
y.eport on research activities during
report on research activities
during
report on research activities during
‘. Initial and acquiredI isoniazid and rifampicin
N.K. Jain et al.
J? ’ , iand
to M. tuberculosis
-- - Its
-- Implications for treatment.
resistance L: No.2;. ppl21-124
..
Ind. J. Tub.; Vol.39 : - tuberculosis operational research in
C. Murray. Opportunities
India; Trip report. Draft 3/1/92. 1992.
District (a sample
Tuberculosis prevalence survey in North Arcot
survey); Draft paper; TRC, 1992.
4.
5.
1
6.
• positive pulmonary patients
M. Datta et al. Assessment of smear
, district tuberculosis programme. Paper
after chemotherapy under the
submitted for publication. TRC;
" . 1992.
Tuberculosis in a rural
pidemiological study. Bull.
7.
8.
WHO, Vol.51 : pp473-488. 1974.
t
&
India).
10.
11.
12.
v. et
. .1
Infection over
al. Prevalence
Prevalence study
study of
of tuberculosis
District (South
1991
Indian J. Med. Res.;
Res., Vol.
vox. 93 : pp74-80.
Er
a.k.
«-i.
of South India: 23-year trend.
pp213-218. 1992.
Tubercle ana
; u tuberculosis prevalence survey in
a
R. Naraln et al. Some aspects ofWHO;
1963.
Vol.29 : pp641-664. 1963.
Bull.
1
a South Indian District. E—
G D Gothl et al. Prevalence of tuberculosis In a South Indian
Sisttlct - Twelve years after initial survey. Ind. J. Tub.; Vol.26 :
No.6; ppl21-135.
197 .
Prevalence of Symptoms in a South Indian rural
D.R. Nagpaul et al.
Indian. J. Med.
community and utilization of area health centres.
Res.; Vol.66 : No.4; pp635-647. 1977.
Ind-
<14j. Tub.; Vol.15 : No.2; pp40-46.
15.
16.'
1988.
and Incidence of pulmonary
• , Changes in prevalence Ind.
S.P. Pamra et al.
J. Tub.; Vol.20 : No.2;
in recent years.
tuberculosis In
1- Delhi
pp57-64. 19 .
tuberculosis in
G.D. Gothl et al. Incidence of sputum positive
follow
up of a rural
different epidemiological groups during 5 year
:
No.
2; pp83-9O.
population in South India. md. J. Tub.; Vol.25
19 .
Q
r
National Tuberculosis Insti
ute. Scientific Report, 1980-1989.2
I
60
i ....
ANNEX 6.2
GENERAL REFERENCES
1.
Murray, Christopher JL. Opportunities for Tuberculosis Operational
Research in India, Trip Report, 3/1/92.
2.
National Tuberculosis Programne, Ind. J. Tub., 1988, 35, 43-45.
3.
District Tuberculosis Programme Introduction Manual, NTI, January
1986.
4.
Nagpaul, D.R. India's National Tuberculosis Programme - An Overview,
Ind. J. Tub. 1989; 36: 205-211.
5.
In Depth Study on National Tuberculosis Programme - An Overview,
Institute of Communication, Operations Research and Community
Development, Bangalore, India. November 1988.
6.
Uplekar M.W. and Shepard D.S. Treatment of tuberculosis by private
general practitioners in India. Tubercle 1991; 72: 284-289.
7.
Murray C., Styblo K., Rouillon A. Health Sector Priorities Review
Tuberculosis. The World Bank. June, 1991.
8.
Chandrasekhar, P. Primary Health Care and Tuberculosis Programme.
1988.
9.
Country Health Profile India GOI/WHO Coordination Cormittee, New
Delhi, May, 1989.
10
NTI, Bangalore, Report on the National Tuberculosis Programme,
.January - March, 1992.
Ministry of Heslth and Fanily Welfare GOI, Annual Report
. 11.
I
r
1991.
WHO Project: Ind Tub 001/B, NTI, Bangalore, India,
Assignment Report, 1987.
Comprehensive Programme Review of National Tuberculosis Programme,
New Delhi, 1992.
13 •
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