INDIA’S NATIONAL TUBERCULOSIS PROGRAMME -AN OVERVIEW
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- INDIA’S NATIONAL TUBERCULOSIS PROGRAMME -AN OVERVIEW
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Ind. J. Tub., 1989, 36, 205
204
the right pattern. Again, 15 percent of the un-implemented districts are in one state
and means could be found to give special care to this state to solve its problems.
Even in the implemented districts, on an average, one third of the PHIs have not
been involved in DTP, for one reason or another. This implies that only two thirds of
the population has in reality been offered the services. If so, how can wo establish
expectations on the basis that the entire population has access to the services. And
then feel dissatisfied that the expectations have not been fulfilled?
Management wise there are some more disquieting factors. The annual targets are
being met only to the extent of fifty per cent; supervision over PHIs by DTO and his
team is also being exercised to that extent, only about 25% of DTPs have fully
trained teams posted and quite a few team members are untrained, implying that,
supervision exercised by them could not be very effective.
Unless and until the constraints are addressed diligently, the noted progress will
fail to satisfy most. It is the right time to improve management in particular and. operations in general and the progress could even be spectacular.
IUATLD PRIZES
The International Union Against Tuberculosis and Lung Diseases (IUATLD) will award four
prizes of US $ 5000 each to two young scientists or physicians working in the field of tuberculosis
and the other two awards will be for scientists or physicians whose work relates to nontuberculous respiratory diseases. For both fields, prizes will acknowledge efforts in developing and
developed countries. Applicants should have distinguished record in research, teaching or in
carrying out public health programmes directed at preventing or treating tuberculosis or other
lung diseases. Only persons under 45 years of age of the end of 1989 are eligible.
Application in English, French or Spanish including curriculum vitae and mentioning age,
attainments and important publications (with copies thereof) should reach the IUATLD
Secretariat (68 Boulevard Saint Michel, Paris 75006) directly or through the Tuberculosis
Association of India (3, Red Cross Road, New Delhi-110 001) before 31.12.89.
INDIA’S NATIONAL TUBERCULOSIS PROGRAMME - AN OVERVIEW
D.R. Naopaul*
Summary : The overview takes into consideration the historical, socio-economic, .
administrative, and technical factors which have played a prominent role in shaping India’s • .
National Tuberculosis.Programme. It comprises an analysis of the current status, trend during
the past ten years and discussion of some aspects that need further attention. Now, a majority
of the constraints are administrative and not even operational, while the needed technical 7
improvements arc few. At the present stage of development, it would appear premature to say
if the programme has succeeded or failed.
Introduction
and population. Thus, the country was to have at
least one bed for each tuberculosis annual death,
An overview of National Tuberculosis
one clinic for 100,000 population, and so on. For "
Programme (NTP) is not a simple matter
understandable reasons, plan progress remained
because many politico-administrative, socio
confined to urban areas. Then the National
economic, operational and technical factors have
Tuberculosis Prevalence Survey, 1955
*1958,
jolted
impinged upon it as well as interacted in various
every one by demonstrating that the tuberculosis
ways and at different times, some factors are, in
problem in India is in reality rural, on account of
fact, part of the wider national ethos, controlled
the predominantly rural population.
by forces beyond technocrats. Any facile opinion
The decade following freedom also brought
about success or failure of NTP at this stage of
into relief socio-economic inadequacies of NTP,
development can, therefore, be correct to an
in the Indian context, despite the logic and use of
extent but cannot be the entire truth.
similar, approach in other countries. Search for a'
Historically, attempts to deal with tuberculosis
better model for NTP began around 1955. The
in the country began sometime after the turn of
then Tuberculosis Chemotherapy Centre, Madras
the present century. Led by voluntary effort, these
and National Tuberculosis Institute (NTI),
attempts had perforce to be sporadic and limited
Bangalore, established to find indigenous
in nature and comprised mostly of sanatoria' in
solutions to the local problems, soon succeeded
the hills. Around the time India gained political
in showing a new way. This more appropriate
independence, the well known Bhorc Committee
technology was found suitable not only for India
Report was published, ushering in the era of
but other developing countries as well. The new
planned health programmes. Justifiably, NTP
technology took into consideration the jell needs
could be deemed to have been born then.
of the people, scarcity of resources, social
Besides, the value of domiciliary treatment having
customs and prejudices, as well as polity, in
been established, it was possible to plan a broad
addition to moulding application of ^scientific
based programme to deal with tuberculosis.
knowledge to the field conditions. NTI
At that time, NTP comprised five more or less
demonstrated
feasibility
and
practical
independent but planned schemes viz. (i) BCG
applicability, and even established the potentials
vaccination of the susceptible population, (ii)
for case-finding and case-holding, before
establishing clinics for diagnosis and treatment of
Government adopted the new basis of NTP in
tuberculosis patients (ni) increasing beds in
1962.
tuberculosis sanatoria and hospitals, (iv) colonies
Since 1962, district-the socio-political unit-is
and vocational centres for rehabilitation of
made the operational unit of NTP. Techno-’
tuberculosis patients and (v) research, roughly in
managerial leadership of district tuberculosis
that priority order. The planning, half a century
programme (DTP) rests with a five member
back, was based on the best technical knowledge
managerial team (Medical Officer, Treatment
• Ex-Dirwor, National Tuberculosis Inatae. Bangalore; K 111, Hauz Khas Enclave, New De!hi 110 016.
n
206
D.R. NAOPAUL
Organizer, Laboratory Technician, X-ray
Technician and Statistical Assistant) posted at the
TB clinic, redesignated as district tuberculosis
centre (DTC). Managerial training, of a uniform
standard, to-DTC teams is given by NTI.
Programme activities are standardised and made
available in the form of manuals by NTI. It is the
responsibility of DTO & his team in DTC, to
involve all peripheral health institutions (PHI) in
the district, in offering DTP services to the
people, either as microscopy or as referring
centres; give in-service training to PHI staff and
supervise their working, for NTP. Besides, there
is provision for State and Central level
programme monitoring, and supervision of the
performance of DTP, from State level, and of
State programmes from the Centre., Within the
above fairly comprehensive structuring, there is
scope for flexibility to suit local conditions, as
long as basic principles are observed. This is
necessary because under the constitution, Health
, is a State subject and all responsibility for
programme implementation and evaluation rests
! with states. An agreed quantum of central
i__ assistance (which includes international aid)
flows to state governments and provides the;
modicum of uniformity on a countrywide basis.
NTI has been monitoring NTP quarterly since
1978. This presentation, therefore, is based on
U those periodic reviews, a recent in-depth study
done by an independent voluntary agency and the
experience of those associated with NTP since its
birth.
Extension of National Tuberculosis Programme
In the nineteen fifties, the approximately 400
million people were spread in roughly 300
districts. Average district population then was L5
million - 80% rural - and number of PHIs around
50, besides the DTC. Since then, the population
has grown to over 800 million. And due to socio
-political reasons, the number of districts has gone
/-J up to 437;. average district population to 1.8
nillion and average number of PHIs to 60, with
improvement in the health infrastructure.
By 1988 end, out of 437 districts, only 371
(85%) had DTP. But at no time since 1962 has
the proportion of implemented districts crossed
the 85% level, nor has the proportion been
improving for many years. Analysis of the 66 non
implemented districts in 16 states/union
territories reveals a mixed bag of reasons, largely
of administrative nature.
NATIONAL TUBERCULOSIS PROGRAMME-
likely reason/
State
Non
Implemented
Districts
Sparse population
5
6
3
5
6
3
1
5
3
8
10
17
12
14
8
9 Statcs/UTs
45 (49%)
92
Q
7
12
Administrative Reasons
Bihar
i
10 (26%)
38
Recent Bifurcation of District
Haryana
Kerala
Maharashtra
Punjab
Rajasthan
U.P
6 States
1
4
3
1
1
1
11 (7%)
12
14
30
12
27
57
During 1988,; an average DTP discovered 4,015
new tuberculosis patients, 322 (8%) of whom
were extra-pulmonary. Of the 3,693 cases <51
pulmonary tuberculosis,ZT83 (21%) were sputum ,
positive of whom 385 were discovered by DTC
and 398 (51%) by around 40 PHIs.
Table 1 shows case-finding performance, as
reported as well as calculated for non-reporting,
according to type of case from 1978 to 1987.
Table 1. Ceding,„ d^ds-^d
eakulaudfordon npeding-
according to type of case under NTP, 1978-1987
152
denied access to the established DTP services.
Nonetheless, why should a proportion of the
population not have access to services near their
homes, so long after the introduction of DTP in
the country? And, for that matter, how many
PHIs in the implemented districts are not
participating in DTP?
In the 371 implemented districts at the end of
1988, around 14,000 PHIs were participating i.e.
on an average 38 out of the estimated 60 PHIs in
each district (63%). It appears that for
administrative/operational convenience, mostly
those PHIs that arc in the semi-urban and more
populated rural pockets have been implemented,
reminiscent of a similar practice for the entire
Case-Finding
Routine quarterly programme reports are the
source of information for a review of activity
performance. But, around 85% of DTP reports
arc received on time and contain information for
around 70% of the participating PHIs, in addition
to that of DTC. A very small number of delayed
reports get included in the next analysis of
performance. Since the non-reporting DTPs are
not the same every quarter, one could project the
reported performance by pro-rata addition of the
Reported
District populations being unequal, nonimplementation of 15% of the districts does not
mean that much population has no DTP cover,
nor that population in the newly carved districts is
207
country. In other words, the entire population has
performance of non-reporting DTP to estimate
not yet been covered by DTPs.,
the overall NTP performance (Table 1).
Attempting a more precise estimate of the
The quarterly programme reports show a wide
population proportion having access to DTP
variability in performance : the fluctuations
services may not be rewarding because, in reality,
observed in the performance of individual DTPs
the population in a five km radius zone of
probably represent the varying inputs of good and
influence around each health institution have
not so good workers; in respect of states, some
I - good access; besides, the people in the zone of
perform consistently well while others do not
influence utilize the facilities to different extent.
impr6vc"aTali, suggesting~thc influence of focal I
The incomplete coverage and varying utilization / administration and work culture. Under the If
of DTP services arc very important to a
circumstances, calculation of average DTP
discussion of expectations from NTP ,
performance i.e. total performance divided by the
performance.
number of reporting DTPs should do for making
comparisons and analysis of trends.
Performance
Total
Districts
Arunachal Pradesh
.Assam
Himachal Pradesh
Jammu &. Kashmir
Manipur
Meghalaya
Mizoram
Nagaland
Sikkim
Union territories
AN OVERVIEW
1978
■
9
I. j
,d
■
Sputum
positives
»
Years
1979
1980
w
1981
1982
1983
1984
1985
1986
1987
128
138
128
130
176
Suspect
cases
210
212
223
227
227
322
366
348
358
514
Extrapulmonary
612
616
685
730
811
41
43
41
40
43
57
62
66
77
90
491
547
517
528
733
879
890
974
1034
1128
Total
■
Calculated
'■£
»
‘|
'1
“
, j
1
Sputum
positives
Suspect
cases
Extrapulmonary
Total
188
185
174
189
219
256
262
259
381
286
473
508
474
521
638
747
764
798
904
1000
6]
58
56
58
66
69
77
76
95
114
704
768
923
1072
1103
1133
1380
1400
722
751
- ~
NATIONAL TUBERCULOSIS PROGRAMME - AN OVERVIEW
D.R. NAOPAUL
208
209
Table 3. Numberofsputa examined annually and percent positivity rate in average
an average DTP and the contribution,,
There is a steady increase in ease-finding during
respectively, from DTP as well as PHIs, along
the last decade, more pronounced from 1982
with the related sputum positivity rates, from
onwards because in 1981NTP was included in the
1978 to 1988. Till 1981, around four and half
20-Point programme of the government and
thousand sputa were examined every year, with
about that time multi-purpose health workers at
positivity rate of 13 percent, in an average DTP;
' the grass roots were involved in case-finding.
of these two thousand eight hundred came from
Since there is no basic difference between the
DTP and seventeen hundred from PHIs, with
reported and calculated case-finding, one could
positivity rate slightly lower in PHIs. A dramatic
say that around 1.5 million cases are now being
change has occurred after 1981. The number of
• discovered annually of whom one fifth are
sputum examinations has risen very sharply, there
4—
sputum positive.
is very- little change in DTP performance, from
The overall case-finding under NTP shown'in
year to year, but PHIs are examining more sputa
Table 1 should be influenced .by population
every year, with a steadily decliriing positivity rate.
increase as /ell as increase in the number.of
It docs appear that a steady plateau of 5%
participating 2)TPs. Table 2 shows the total cases
positivity rate has been reached in respect of
found per J 1,000 population as well as number
PHIs too, and there may be no further decline.
of sputum examinations done and sputum
The significance of the decline in positivity rate is
positive cat found in an average DTP to obviate
discussed later.
the influcr of the two factors. Table 2 not only
As mentioned in the introduction, PHIs hold
underline? e findings of Table 1 but shows that
an important position in DTP because they cater
the gain u. sc-finding has been obvious.
to 80% of the population. With a declining
In 19
two operational changes were
positivity rale, doubts mayarisc as to the real role
_
introduced in the case-finding technology, targets
of PHIs. Table-4 examines this point : the per
were introduced for the number of sputa to be
cent contribution of PHIs in respect of total sputa
r^’*
'^£,<u£xamined every year and multipurpose workers
examined, sputum positive cases found and total
were lo collect sputa from symptomatics during
case-finding of an average DTP, from 1978-1988.
1^.| their home visits. It should be useful to examine
It is indeed satisfying that during the last ten
' their effect on the quality of sputum examination.
years, the PHIs share in sputa examined has risen
Also, if the change influenced the relative
from 36% to 72%, in sputum positive cases from
contribution to case finding made by PHIs, where
31% to 51% and in total case-finding from 30%
multipurpose workers operate.
to 47%.
Table 3 gives the number of sputa examined in
Table 2. Tomi
found P" 100,000population and in grams'DTP (MS io MS)
Total Cases
per 100,000
AVERAGE DTP
’r-;' 1978
1980
1981
1982
1983
1984
‘D J.?.'.
1985
-
l
..
'
.•
1986
1987
1988
Cq;.
'
%
DTC
%
64
PHIs
%
DTP
DTC
PHIs
1978
4434
100
2859
1979
4685
100
2971
1980
4531
100
2830
1981
4493
100
2687
1982
5585
100
2895
1983
7495
100
2908
9140
100
2913
1985
32
6227
9951
68
100
8
3013
13
30
6938
6
1986
70
10476
7
3098
12
29
5
7378
71
7
13
5
7
12
5
“12
5
1984
100
1574
36
14
15
12
1714
37
13
13
62
11
1701
38
12
60
13
1806
11
40
10
10
52
10
2690
48
11
39
13
9
4587
61
10
14
7
1987
11542
100
3227
1988
28
8315
72
11848
100
3359
28
8489
72
Table 4. Pertent contribution from PHIs in respect of
sputa examined and sputum positive as well
as total cases found annually in an average
districtfrom 1978 to 1988
Per cent contribution from PHIs
in respect of
Year
i
Percent Possibility
Number of sputa examined
DTP
i
Case-Finding
.
DTP, DTC and PHIsfrom 1978 to 1988
Year
Sputa
examined
Sputum
positive
cases
Total
cases
1978
36
31
30
1979
37
34
32
1980
38
34
1981
33
40
35
1982
33
48
40
37
1983
61
45.
1984
43
68
48
44
Sputum Exams
Sputum Positives
1985
70
603
29
50
1986
44
4,434
70
4,531
546
26
; 1987
1 1988
43
4,685
28
49
586
4,493
536
28
5,585
620
31
7,495
725
36
9,140
735
36
9,951
735
36
10,476
769
37
11,542
772
37
11,848
783
38
72
50
46
72
51
47
Treatment and Case Holding
Information on these aspects is comparatively
incomplete. During 1988, on an average 4,700
tuberculosis patients per DTP were put on
treatment. Of the 4,000 newly discovered cases
during the year, around 5% did not start
treatment (initial default), while 25% got added
on account of ‘transfers in’ and ‘restarted
treatment’. Only about 30% of DTPs reported
cohort analysis, according to which only 27% had
completed twelve monthly drug collections or
more.- Default in drug collections is frequentmore in urban arcas-and taking of defaulter
actions infrequent. Sputum examination at the:
end of treatment completion is infrequent too,
making any observation on sputum conversion
unrealistic.
Since no appreciable improvement in
treatment completion occurred after 1981, and
the potential for treatment completion with
standard regimens, in an NTI operational study,
was no better than 45%, it was decided, in 1985,
to try out six-month short course chemotherapy,
despite some doubts regarding the capability of
present day DTP case-holding. Eighteen DTPs in
the South were placed under supervision of the
Tuberculosis Research Centre, Madras for this
purpose. Treatment completion, on an average,
has improved to 52% with the six-month drug
regimens. And, another group of 176 DTPs have
been assigned to NTI to see if short course
chemotherapy will give similar results under the
routine supervision of DTC teams. Since
treatment compliance with the standard drug
regimens, at the sixth month of therapy, is also
around 50% to 60%, it is believed that case
holding and treatment completion can be
improved to around sixty percent level, under
r n-
j?'
210
DJR. NAOPAUL
NTP, by switching over completely to short
course chemotherapy.
most DTPs and the supply of drugs—not so much
the stock of drugs as their distribution and
quality-and other expendables leaves much to be
Management
desired.
Discussion
The management aspect of NTP does not look
as rosy as the activities discussed above. The
Twenty five years after the adoption of DTP,
incomplete extension & coverage of population
the NTP presents a picture of encouraging
by NTP has been described. Training
progress and frustrating constraints.
management, of DTC teams is another similar
Since 1978, when central monitoring of NTP
example. Since 1962, over 4,800 team personnel
began, the number of DTPs has gone up from 313
or roughly 900 full teams have been trained by
to 371; the average number of sputum
~NTI. But in 1988, only one fourth of the 371
examinations per DTP in a year has increased to
implemented districts had trained full teams in
nearly three times; x-ray examinations by one and
their DTCs, while 70% DTPs had the services of
a half times; total new cases found are now twice
Va trained DTO (team leader). This position is
in number and sputum positive cases one and a ? .
much beyond the usual attrition rate and suggests
half times (from 0.2 to 0.3 million every year);-’a casual attitude towards managerial training and
and contribution of PHIs in case-finding has.
posting of full teams for proper management.
increased from 30% to 47%. Now , 15 million |
Some administrators even question the role of
new cases are found every year of which around
managcrialTcarnsToTDTPs when the programme
8% are extra-pulmonary, 72% suspect cases and.
is running ‘smoothly
*
despite incomplete teams
20% sputum positives. Treatment completion has I
arid some tcanTmehibtrs being untrained.
improved from about 30% with standard drug .•
.Many DTP reports have the column of
regimens to 55% with short course .
supervisory visits paid to PHIs left blank Rest of
chemotherapy. This progress may not be
the reports show that only 40 to 50 per cent of the
spectacular but is surely notable.
scheduled visits arc made. It is a common
Management wise, the coverage of population
observation that the more conveniently located
with DTP services has, perhaps, not gone beyond
PHIs are visited repeatedly and some not visited
60%; the annual sputum examination targets are
at all; 'also, that more frequently the supervision is
being met to the extent of 50%; only 25% of
half-hearted. No wonder that one third of the
DTCs have full trained teams posted; supervision
PHIs on an average are left un-implemented. As
over PHIs does not exceed 50% of scheduled
regards supervision from the Central level, only
visits, and so on. Nevertheless, this state of affairs
sixjer cent of the scheduled visits to the States
is not confined to NTP alone : barring a few
j I were paid in 1988 and supervision exercised by
exceptions, it is part of the national scene and
•1 the States over their DTPs was no better. Central
reflective of a society in flux.
monitoring of NTP is excellent but monitoring at
Besides inadequate management, some of the
the^State level, and corrective actions following
basic concepts underlying DTP, and the attitudes
monitoring as well as supervision, leave much to
that go with them, have not yet completed their
full evolution. There appears to be a stalemate in
be desired.
Every year modest targets arc set for sputum
respect of integration. Despite a much wider
examinations but these targets are being met to
acceptance of the idea than before, there is
no more than 50%. Still, case-finding under NTP
insufficient
structuring,
devolution
of
has improved satisfactorily. It stands to reasons
responsibility and powers, and budgeting
that if management were better and supervision
procedures to let integration play its role fully and
more effective, achievement of targets would be
bring in the envisaged benefits. In some states,
far better, case-finding superior in numbers and
and in selected areas in other states, it could be
proportion of sputum positive cases, and case
that integration introduced in the sixties has
holding able to reach the promise of
begun to disintegrate, creating confusion and
making the services more vulnerable. Similar
chemotherapy.
Equipment is in working order in 90% of
confusion prevails regarding the purpose and role
DTPs; supervisory vehicles in 60% of DTPs;
of multipurpose workers at the grass roots. The
budgets - especially for travel - are inadequate in
NATIONAL TUBERCULOSIS
PROGRAMME
AN OVERVIEW
211
same could be said regarding the concept of
leading to improvement in case-finding as such,
voluntary and private sector collaboration and co
and the relative contribution from PHIs, on the
ordination with the DTP services in the district.
other hand a doser examination of around 30%
Considerable efforts have been made in enlisting
to 40% achievement of the expectations has
their co-operation by arranging for the staff of
suggested an clement of unreality in the earlier
these two sectors, seminars and workshops,
potential studies. True, those studies were carried
supply of drugs for free distribution for their
out under DTP field conditions, strictly according
patients, offer of diagnostic services in respect of
to programme manuals. But the study staff
problem cases and even home visiting to retrieve
belonged to NTI. That staff had motivations and
the defaulters. The progress, however, has been
work ethos quite different from the attitudes and
disappointingly small and slow. Attitudinally,
application to work found among general health
these three sectors sec their role in competition
services staff. The potential studies served a very
rather than extending complementary and
useful purpose by establishing credentials of-DTP
supplementary assistance to each other for the
at that point of time. If we have to use those
same beneficiaries.
results for the formulation of expectations, then
Operationally, the referral system vital to
we must repeat the studies in exactly the same
integrated functioning is almost non-functional.
manner but use average general health staff for
Studies are needed urgently to understand
carrying out the activities under the overall
the reasons. Another operational aspect
surveillance
of NTI staff. Even otherwise, there is
needing urgent study is the phenomenon of
need to repeat some operational studies under
falling sputum positivity rate. When the
the present day changed conditions.
operational base for selection for sputum
Technically, there are hardly, any major _ (
examination is widened, a certain fall in positivity
problems. Perhaps, two points could be looked
rate can be expected. What is disquieting is the
into by NTI. One relates to the reason .why \
large gap in the fall between DTC and PHIs,
sputum positive cases,, among the symptomatics, I
which is understandable to an extent, but needs
cofifiriuc to remain around 20% while the suspect i
investigation to make sure. It would be premature
cases constitute the bulk i.e., 72% of the total new
to conclude that there has been a fall in the
cases found. It is likely that following integration,
quality of sputum examination, or similar other
there has been a fall in the quality of x-ray
assumptions.
reading : Steps may have to be suggested to
An operational factor of great importance is
the formulation of expectations based on the
control the extent of over-reading, if any. The
early NT1 studies on the potential of case-finding
second point is to carry out field trials of a
and case-holding under DTP. The gap betweep
suitably modified model of DTP which is
expectations and actual performance is large
applicablejothc_remote-hilly-districts with-sparsc .
enough to cause dissatisfaction. On the one hand
population. This should help to speed up the
these-comparisons have helped in focussing
implementation of those districts which have
attention on certain aspects of performance
been left out of NTP for so long.
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