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Tuberculosis (TB) is a major public
health problem in India.
India
accounts for one-fifth of the global TB incident cases. Each year over 1.9
million people in India
develop TB, of which around 0.87 million are infectious cases. It is
estimated that annually around 325,000 Indians die due to TB.
Since 1993, the Government of India (GoI) has been implementing the
WHO-recommended DOTS strategy through the Revised
National Tuberculosis Control Programme (RNTCP).
The revised strategy was pilot-tested in 1993 and launched as a national programme in 1997. By March
2006, the programme was
implemented nationwide in 633 districts, covering 1114 million (100%) population. Phase II of the RNTCP started from October
2005, which is a step towards achieving the TB-related targets of the
Millennium Development Goals.
The objectives of RNTCP are:
 To
achieve and maintain at least 85% cure rate amongst New Smear Positive (NSP)
pulmonary TB cases.
To
achieve and maintain at least 70% detection of such cases.
The structure of the RNTCP comprises
of five levels; National, State, District, Sub-district and Peripheral health
institutions. The Central TB Division which is a part of the Directorate
General of Health Services, Ministry of Health and Family Welfare (MoH&FW), GoI, is responsible for
tuberculosis control at the national level, and is headed by a Deputy Director
General (TB).
At the State level, the State
Tuberculosis Officer is responsible for planning, training, supervising and
monitoring the programme
in their respective states. The District TB Officer has the overall
responsibility of physical and financial management of RNTCP in the
respective districts. An innovation of RNTCP is the creation of sub-district
“Tuberculosis Unit” supervisory and monitoring team, for an approximate
population of 500,000, (250,000 in tribal and difficult areas), comprising of
a designated Medical Officer – TB Control, a Senior Treatment Supervisor and
a Senior TB Laboratory Supervisor, based in either a Community Health Centre,
Taluk Hospital or Block
Primary Health Centre.
RNTCP has established across the
country more than 12,000 quality assured designated microscopy centres (DMC) providing sputum
microscopy services, each DMC covering roughly a population of 100,000
(50,000 in tribal and difficult areas). Patients are provided directly
observed treatment (DOT) by either a health care worker or a community
worker/volunteer at hundreds of thousands of sites called DOT-centres. The entire course of
anti-TB drugs for individual patients is packaged in a ‘patient wise box’
which simplifies drug logistics, restores the confidence of the patient on
the health system and ensures that the patient never interrupts treatment due
to want of drugs.
The programme has developed standardised training modules for all categories
of staff and documents and guidelines on various aspects of the programme. Based on the
consensus between RNTCP and Indian
Academy of Pediatrics,
the existing RNTCP guidelines for the diagnosis and treatment of pediatric
cases have been modified and published. A web based resource centre for
Information, Education and Communication has been developed. Researchers are
being encouraged to conduct operational research in identified key areas
Consistently since 2002, the
expansion of RNTCP has accounted for significant proportion of the additional
smear-positive cases reported under DOTS globally. The programme to
date has treated over 8 million TB patients, with nearly 1.5 million
registered for treatment in 2007 alone. The programme has achieved a treatment success rate of
over 86% and the case detection in 2007 was 70%. Death rates under RNTCP have
been cut 7-fold compared with those under the previous programme
(NTP), from 29% to 4.6% among new smear positive cases. With an approximate
18 additional lives saved per 100 patients treated under RNTCP, the programme
has substantially reduced deaths amongst patients treated and saved an
estimated over 1.4 million additional lives since its inception.
RNTCP
has developed partnerships with a wide range of stake holders. To date more
than 2900 NGOs, over 17,000 private practitioners,
261 Medical Colleges and over 120 corporate sector
health facilities are involved in the programme. Public-private mix (PPM) DOTS has a
significant role in achieving the national objectives of case detection and
treatment outcomes. National, Zonal and State task forces have
been created for the involvement of the medical colleges in the RNTCP.
Significant headway has also been made towards the involvement of the
Employees’ State Insurance, Central Government Health Scheme, Railways, Armed
Forces, Corporate Sector and other Public Sector Undertakings in the programme. Since 2003, PPM DOTS
activities have been ongoing in almost all parts of the country.
Joint TB-HIV activities, in
collaboration with the National AIDS Control Organisation were started in 2001, initially in
the 6 high HIV prevalent states. These activities were subsequently expanded
to 14 states and in 2007 a decision was taken to scale-up to the entire
country. For this purpose a National TB/HIV Framework has been developed
jointly by both programmes
and a Technical Working Group meets regularly to advise both programmes on technical
guidelines and related policy issues.
Having successfully expanded DOTS
services to the entire country, RNTCP is now operationalzing a plan to offer treatment for
patients with multidrug-
resistant TB (MDR-TB) at DOTS-Plus sites. RNTCP DOTS-Plus guidelines are
an adaptation of the international guidelines on programmatic management of
drug resistant TB. In 2007, treatment for MDR-TB patients has started at
two sites, one each in Gujarat and Maharashtra. RNTCP plans to scale
up DOTS Plus services to 24 sites across the country in the next two years
and one of the important activities in this process is laboratory
strengthening for quality assured culture and drug susceptibility testing.
The RNTCP has also developed a response plan for the recently defined extensively
drug resistant TB (XDR-TB) which has also been reported from a few
institutions in India.
In 2007, a consensus statement on XDR
and MDR TB has been developed following a meeting of experts in Chennai.
The majority of funding for RNTCP is
from the Government of India sources which includes
a World Bank credit. The programme
is also supported with funds from donor agencies including DFID, GFATM and
USAID. The Global Drug Facility (GDF) procures about half of the drug
requirement of RNTCP using funds from DFID.
WHO is supporting the RNTCP by
providing technical assistance through a network of about 100 field level
Consultants who work closely with the district and state TB officers. At the central level, two international and one
national WHO staff provide technical assistance to the Central TB Division, MoH&FW, GoI. WHO India has
provided technical support to the RNTCP in the following major areas:
1. In
surveillance, quality assurance, TB/HIV collaboration, reporting and data
management and in drugs and logistics management.
2. In
the development of the strategy document for the supervision and monitoring
of the RNTCP, guidelines for the quality assurance of smear microscopy for
diagnosing tuberculosis, concise module on RNTCP for medical practitioners
and the training modules on TB/HIV.
3. In
the revision of the guidelines and technical modules for all types of staff
under RNTCP.
4. In
the conducting of the national review meetings of the State TB Officers and
field consultants in addition to several other meetings with the partners.
5. In
the start-up of MDR-TB management, including in development
of the RNTCP DOTS-Plus guidelines, in the development of the GLC application,
initiation of services for MDR-TB patients and developing a response plan for
addressing XDR-TB.
6. In the strengthening of reference laboratories for quality
assured culture and drug susceptibility testing, including testing for first
and second line drug susceptibility and evaluation of newer laboratory
techniques for the purpose.
7. In
organizing national and zonal meetings of the task
force for the implementation of RNTCP in the medical colleges.
8. In
the preparation of the project implementation plan (PIP), for the period
2006-2010, for securing funds from the World Bank and other funding agencies.
9. In
negotiating with funding agencies for anti-TB medicines and financial support
to maintain the field consultants’ network.
10. In enhancing the PPM activities under RNTCP, including the
use of the international standards of TB care in involving professional
medical associations.
11. Technical
support to TB-HIV activities of the RNTCP.
12. In
the research activities with Tuberculosis Research Centre, Chennai and with
other agencies and in the surveys to assess the impact of different
tuberculosis control measures.
13. Technical
support to National TB Institute in operational research and impact
assessment surveys.
14. In
the development of GFATM proposals and in the monitoring of the
implementation of such projects
WHO’s
technical assistance to RNTCP is supported through partnerships with CIDA,
DFID and USAID.
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