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RNTCP and PPM DOTS
The Revised
National Tuberculosis Control Programme (RNTCP)
based on the internationally recommended DOTS strategy was initially
implemented mainly through the network of health care facilities under the
public health departments of the state governments. In India, the health care sector is
very diverse and there are many non-MOH government departments and non-public
sectors which have their own health care facilities. Studies have shown that
the private sector is the first point of contact for more than half of the TB
patients.
Realizing the significant roles that the various
health sectors could play in TB control, the RNTCP has been establishing collaborations
with a wide range of health care providers which have resulted in many unique
models of Public- Private Mix (PPM) in RNTCP. These models in addition to
contributing to additional TB case detection, have also paved the way for
policy decisions in the area of PPM DOTS. The government is committed to
provide quality assured free treatment to TB patients in the country
irrespective of the health care sector from where they seek treatment. Thus
the PPM DOTS in India
is a strategy to diagnose and treat TB patients under RNTCP utilising a mix of different types of health care
providers
Important
PPM DOTS projects
The ‘Mahavir hospital
model’ in Hyderabad,
which started in 1995, where an NGO hospital was given the responsibility to
manage a tuberculosis unit (TU), was the first major PPM DOTS initiative
under RNTCP. In the ‘Kannur model’ of Kerala state, involvement of major private hospitals and
laboratories led to a 15-20% increase in case detection. In Mumbai,
involvement of private practitioners facilitated by three NGOs contributed
7-16% to case detection. Falah-e-Am, an NGO in Meerut
gave 17% of the cases detected in the district. In Jalpaiguri
(West Bengal) and Dibrugarh (Assam), the tea garden hospitals
involved as microscopy centres, contributed 44% and
39% of cases detected respectively.
Using the experience gained from such collaborations
with the private and NGO sectors, the RNTCP developed national guidelines for
formal collaborations with private practitioners and NGOs at the district
level. Initiatives to involve the medical colleges resulted in the formation
of national, zonal and state task forces of medical colleges, and core
committees within individual medical colleges. RNTCP has also involved
corporate sector units such as tea gardens in the North-East and West Bengal,
and Coal India in West Bengal. Health care facilities under central
government departments (Employees State Insurance, Railways, Petroleum,
Ports, Mines etc.) have also adopted RNTCP. The
district TB control societies all over the country are being encouraged to
collaborate with all suitable local partners. A study on the feasibility and
effectiveness of the PPM DOTS in Hyderabad and
New Delhi
revealed that the cost to the society per patient cured was lower in PPM DOTS
compared to public sector RNTCP. Economic evaluations conducted recently in Bangalore revealed that
by involving non-public sectors in RNTCP, the number of cases treated under
RNTCP increased, while the average societal cost per patient treated fell
from US$123 to US$87, including all direct and indirect costs to patients.
These studies conclude that PPM DOTS could be cost effective and reduce the
financial burden on patients and society
Countrywide scaling up of PPM DOTS
As an initial step in the country wide scale up of
PPM, the RNTCP in September 2003 launched an “intensified PPM DOTS”
initiative in 14 major urban districts of the country. RNTCP-WHO (PPM)
medical consultants were posted in these districts to provide technical assistance
to the respective state and district TB officers. These sites implemented PPM
in a very systematic manner, and a modified surveillance system to the
routine RNTCP one was implemented in these districts. To provide
disaggregated data, the health care providers were broadly classified into
six categories viz. state health department facilities, government facilities
outside state health department, medical colleges, corporate sector, private
hospitals and practitioners, and the non-governmental organisations.
The 14 intensified PPM sites together show a steady
and gradual increase in case detection. The analysis of the quarterly data
from the intensified PPM districts revealed the enormity and diversity of the
health care provider categories. It also provided valuable information on the
role and contribution of the various health care provider categories in the
management of TB cases. A higher proportion of cases was
detected by the medical colleges and larger hospitals. In all sites, the
State government health sector had remained the largest contributor to case
detection. Medical Colleges, though fewer in number, contribute 15 to 20 per
cent of all the cases detected. The NGO sector is also an important source
for care in TB. By January 2006, the intensified PPM was expanded to a total
of 70 districts.
The RNTCP has recognised
the Indian Medical Association (IMA) as a major partner in expanding PPM DOTS
services in the country. The IMA has nominated national and state level
coordinators for RNTCP. The RNTCP and IMA have together conducted one
national and eight state level workshops on PPM DOTS which were attended by
IMA leaders and RNTCP key staff. The IMA in Kerala
state, with support from WHO, has organized training on RNTCP for more than
1000 private medical practitioners. A senior member of the Indian Medical
Association (IMA) was nominated by the RNTCP to be the representative of a
professional association from India
on the global steering committee, which supervised the development of the
International Standards for TB care (ISTC) document. With the assistance of
IMA and WHO technical support, a coalition of professional medical
associations has been established to assist RNTCP in TB control activities in
the country. In 2007, the IMA in
collaboration with RNTCP, launched a GFATM-assisted
project in 6 states to systematically enlist, sensitize, train and involve
private practitioners in the programme.
Bigger NGOs like World Vision, mission hospital
associations like Christian Medical Association of India (CMAI), Christian
Health Association of India (CHAI), R.K. Mission etc
are collaborating with RNTCP at national and state levels.
The vast majority of medical colleges in the country
have already established a RNTCP designated microscopy cum treatment centre
in their respective institutions. The National Task Force (NTF), under the
leadership of the All India Institute of Medical Sciences (AIIMS), has organised since 2002 annual National Task Force
workshops. The NTF has endorsed the ISTC and issued a strong statement on the
rational use of second line anti-TB drugs and the prevention of MDR and XDR
Tuberculosis.
RNTCP has developed and disseminated an advocacy kit
containing special material and documents for sensitising
private medical practitioners on RNTCP. A concise training module for medical
practitioners has also been developed by RNTCP. This module has a shortened
duration of training of 6 hours. The RNTCP encourages operational research on
PPM DOTS. Priority topics identified for research are available on the RNTCP website (www.tbcindia.org).
An operational research study on the economic
evaluation of the intensified PPM DOTS, was launched
in Bangalore
city in 2005. The National TB Institute (NTI) Bangalore, which is a WHO collaborating
centre, is the nodal agency for the study. About 1050 patients have been
surveyed and the results are currently being analysed
Current status of involvement of health
care sectors in RNTCP
To date more than 2300 NGOs, over 15,000 private
practitioners, 246 Medical
Colleges and over 120
corporate sector health facilities are involved in the programme.
Future plans
The RNTCP plans to further scale up nation wide PPM
activities. All the major stakeholders in health care sectors will be
encouraged to adopt RNTCP, which provides the ways and means to practice TB
care which meets the international standards of TB care. Access to services
will be widened through the scaling up of inter-sectoral
collaborations as well as by improving the delivery of quality RNTCP services
through all the existing health providers such as medical colleges, NGOs,
private sector and health facilities under other non-MOH ministries. The ISTC
will be used as a tool for the involvement of the remaining health care
providers in RNTCP
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