Tuberculosis (TB) is a major
public health problem in India.
accounts for one-fifth of the global TB incident cases. Each year nearly 2
million people in India
develop TB, of which around 0.87 million are infectious cases. It is
estimated that annually around 330,000 Indians die due to TB.
Since 1993, the Government of
India (GoI) has been implementing the
WHO-recommended DOTS strategy
via 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.
Since 2006, RNTCP is implementing the WHO recommended “Stop TB Strategy”, which in addition to DOTS, addresses all the
newer issues and challenges in TB control.
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.
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 about 10 million TB patients, with over 1.5 million
registered for treatment in 2008 alone.The programme
has achieved a treatment success rate of over 86% in new smear positive cases
and the case detection in 2008 was 72%. Death rates under RNTCP have been cut
7-fold compared with those under the previous programme
(NTP), from 29% to less than 5% 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 1.7 million additional lives
since its inception.
RNTCP has developed partnerships
with a wide range of stake holders. To date more than 2500 NGOs, over 19,000
private practitioners, 267 Medical
Colleges and over 150
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
Having successfully expanded DOTS
services to the entire country, RNTCP is now scaling-up 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 was started at two sites, one each in Gujarat
and Maharashtra. By the end of 2008, 190
MDR-TB patients were on treatment in seven states. RNTCP plans to scale up
DOTS Plus services across the country in order to achieve universal coverage
by 2012 for all re-treatment cases notified under the programme.
One of the important activities in this process is laboratory strengthening for
quality assured culture and drug susceptibility testing, including the use of
recently recommended newer technology for rapid detection of MDR-TB. The
RNTCP has also developed a response plan for the 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 was 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 of UK, the Global Fund 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 90 field level
Consultants who work closely with the district and state TB officers. In
addition about 10 Consultants provide technical support to the Central TB
Division. At the WHO Country Office,
five international staff, 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
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
8. In the preparation of funding
proposals and multi-year project implementation plans 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
10. In enhancing the
Public-Private Mix (PPM) activities under RNTCP, including the use of the
international standards of TB care in involving professional medical
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 GF
proposals and in the monitoring of the implementation of such projects
WHO’s technical assistance to RNTCP is
supported through partnerships with DFID and USAID.