A rapid appraisal of organisation , implementation and utilization of DOTS in Jammu district

Supervisor : Dr S.Vivek Adish

BY DR Vinay Chib

National Institute of Health and Family Welfare Munirka, New Delhi-110067

Table 1 Acronyms AIDS Acquired Immunodeficiency Syndrome CHC Community Health Centre CTD Central TB Division DANIDA Danish International Development Agency DTC District TB Centres DTO District Tuberculosis Centre DMC Designated Microscopy Centre GDP Gross Domestic Product

HDI Human Development Index HIV Human Immunodeficiency Virus MO Medical Officer MOTC Medical Officer Tuberculosis Centre

MDR-TB Multi-drug Resistant TB

NTP National Treatment Program PHC Primary Health Care Centre RNTCP Revised National Tuberculosis Control Programme SIDA Swedish International Development Agency STC State TB Cells

STO State Tuberculosis Officer STLS Senior Tuberculosis Laboratory Supervisor STS Senior Treatment Supervisors TB Tuberculosis TBHV Tuberculosis Health Visiter TU Tuberculosis Unit USAID United States Agency for International Development WHO World Health Organization.

INTRODUCTION :-

GLOBAL BURDEN OF TB
Tuberculosis is the leading cause of death from a curable infectious disease caused by Mycobacterium Tuberculosis. TB has affected mankind for over 5000 years and is still continuing to be a leading cause of morbidity and mortality. More than 1.3 million people die of this disease every year. Nearly 1/3rd of the worlds population is infected with tuberculosis Bacilli and approximately 10% of them have a lifetime risk of developing TB disease. In 2008, there were estimated 9.4 million new cases equivalent to 139 cases per 100,000 population of TB globally. TB-HIV co-infection and drug resistant tuberculosis has aggravated the TB situation globally. Of the 9.4 million incident cases in 2008, an estimated 1.4 million (15%) were HIV positive. MDR TB (Multi Drug Resistant TB ) is emerging as a major challenge to the programme managers. There were an estimated 0.5 million cases of MDR TB in 2007.
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TB DISEASE AND TREATMENT TB is caused by Mycobacterium tuberculosis and is spread through airborne droplets (Frieden et al., 2003). More than 80% of people with active TB have pulmonaryTB (World Health Organization, 2005), which can be infectious or non infectious. There are two steps that are associated with the development of TB. The first is infection by M. tuberculosis, which usually occurs through close exposure to persons with infectious TB. This first step leads to latent TB infection, which is asymptomatic and non-infectious (Global Alliance for TB Drug Development, 2001). Nearly one-third of the worlds population has latent infection by M. tuberculosis and could develop active TB at any time (World Health Organization, 2003). Within months to years after the initial infection with the TB bacteria, approximately 10% of infected people develop active TB (Global Alliance for TB Drug Development, 2001). Untreated, a person with active TB disease will infect 10-15 people annually (World Health Organization, 2005). Conditions that increase the likelihood of active infection include HIV, malnutrition, vitamin D or A deficiency, underlying malignant disease, or other medical conditions (Frieden et al., 2003).

TUBERCULOSIS BURDEN IN INDIA

India is the highest TB burden country accounting for 1/5th of global incidence. Every year approx. 18 Lac people develop TB and about 4 Lakh die from it. In India EVERY DAY: More than 40,000 people become newly infected with tuberculosis bacilli. More than 5000 develop TB disease. More than 1000 people die of TB(i.e. 1 death every 11/2 minutes.) In 2008, out of estimated global incidence of 9.4 million cases, 1.98 million cases were from India. ESTIMATED BURDEN OF TB IN INDIA No of million (95%CI) Rate per lac person(95%CI) Incidence( WHO estimate 2009) All cases AFB smear positive Period Prevalence(2000-GOI estimate) AFB positive Bacillary Prevalence all cases(2000 WHO est) Prevalence All cases

1.982 0.885

168 75

1.7 3.8 4.968 3.304

8

165 369 443 283

(2007 WHO estimate) Prevalence all cases (2009 WHO estimate)

2.186

185

TB-related Millennium Development Goal Goal 6 to combat HIV/AIDS, malaria and other diseases Target 8 to have halted by 2015 and begun to reverse the incidence of malaria and other major diseases, including tuberculosis. Indicators for Target 8 to be used to evaluate the implementation and impact of TB control: Indicator 23: Between 1990 and 2015, to halve the prevalence and death rates associated with tuberculosis; and Indicator 24: by 2005, to detect 70% of new smear positive TB cases arising annually, and to successfully treat 85% of these cases.

PROGRESS TOWARDS MDG INDICATOR 23 Prevalence rate of TB

Mortality rate of TB

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The revised National TB control program (RNTCP) based on internationally recommendations Directly Observed Treatment Short Course (DOTS) Strategy was launched in 1997 and was expanded across the country in a phased manner with support from the World Bank and other development partners. The objectives of the program are to : a) To achieve and maintain cure rate of at least 85% among New Sputum positive patients. b) To achieve and maintain case detection at least 70% of the estimated NSP cases in the community. The only effective means by which 85% cure rate or more has been shown to be achieved able on a programme basis is by application of the DOTS strategy. DOTS is a systematic strategy which has 5 components:1. Political and administrative commitment. 2. Good quality diagnoses by sputum smear microscopy. 3. Uninterrupted supply of good quality drugs. 4. Directly observed treatment. 5.Systematic accountability

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GOAL of RNTCP:

Cure at least 85% of the registered New Sputum Positive Cases Detect at least 70% of the estimated New Sputum Positive cases existing in the community (67-95 cases per lac/year) Indicators Expected Value/Range 2%-3%

S No 1 2 3 4 5 6 7 8 8

Chest Symptomatic among Total Adult OPD

Positive cases to be found in chest symptomatic 8%-12% cases examined Annualized Total Case Detection Rate(ACDR) 180257 cases/Lac/Year

Annualized New Sputum Positive Case Detection 6795 cases/Lac/year Rate Conversion rate of New Sputum Positive Cases >90% at 3 months Cure Rate Among New Sputum Positive Cases Death Rate among NSP Cases Default rate Failure Rate among NSP Cases >85% <4% <5% <4%

REVIEW OF LITERATURE

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Tuberculosis (TB) is a serious global health threat, infecting more than 8 million people with the active form of the disease and killing almost 2 million people each year. TB control and treatment has become a growing concern in developing countries, particularly in India, where more than 20 percent of new TB cases occur annually (World Health Organization, 2005). The public health sector of India is ill equipped to deal with this burden, having a shortage of functioning public health infrastructure (Bajpai and Goyal, 2004). This shortage leads to further economic and health consequences for those infected with TB as they often go into debt to seek treatment from the ill-regulated private sector; they use the private sector as an alternative to seeking care from the public sector, which is often perceived to be of poor quality (Bajpai and Goyal, 2004; Gupta,2005; Rajeswari et al., 1999). Previous national TB control programs in place in India since the advent of drugs to treat the disease in the 1960s were proven inefficient and ineffective at properly detecting and treating TB.Globally, national governments and international aid organizations have joined forces to combat this epidemic by implementing functioning public health care programs using the Directly Observed Treatment, Short-Course (DOTS) strategy. In India, this effort has taken the form of the Revised National Tuberculosis Control Programme (RNTCP), one of the two largest programs of its kind in the world both in terms of population coverage and number of patients treated (World Health Organization, 2005). The RNTCP, first tested at a pilot level in 1993, was implemented in almost all districts of India through the existing public health infrastructure by 2005 (Agarwal and Chauhan 2005). Financed primarily as a centrally funded (with assistance from external loans and grant aid) disease control program, the RNTCP also requires state initiative and inputs for its implementation. The program is implemented at the district level, which is the lowest level of administrative division in India. The need for increased TB control in India is apparent, as evidenced by the fact that there are almost 2 million new cases of active TB each year in India alone (World Health Organization, 2005). The potential economic benefits of implementing a well functioning DOTS program in India have been estimated at $750 million (in 1993-1994 prices) annually (Dholakia and Almeida, 1996). The primary mechanism currently in place under WHO guidelines for the global control of TB is the worldwide implementation of functioning DOTS programs. DOTS, originally an acronym for directly observed therapy, short-course, is now used to describe a broader WHO public health strategy for TB control (Onyebujoh et al., 2005).

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There are five aspects that comprise the DOTS strategy: sustained political commitment; access to quality assured TB sputum microscopy; standardized short-course chemotherapy for all cases of TB under proper case management conditions, including direct observation of treatment; uninterrupted supply of quality-assured drugs; [and a] recording and reporting system enabling outcome assessment of all patients and assessment of overall programme performance (World Health Organization, 2003). The DOTS strategy requires the use of sputum smear microscopy for the diagnosis of pulmonary TB (Global Alliance for TB Drug Development, 2001). Treatment programs are given under intermittent conditions (preferably three times per week) and must be directly observed by a health care provider or trained community member (World Health Organization, 2003). The standard treatment regimen is for a duration of six months and costs as little as $11-$17 in developing nations (World Health Organization, 2005a). DOTS has been shown to be an extremely cost-effective treatment strategy; some studies claim that DOTS is the most cost-effective of all health interventions available. Others indicate that it costs as little as $1-$4 per discounted year of life saved (Ahlburg, 2000). In India, conservative estimates show that the potential tangible benefits of DOTS implementation are on the order of US$750 million per year (Dholakia and Almeida,1996). Strict supervision and monitoring is very important component in RNTCP. A study on effectiveness of DOTS on Tuberculosis patients treated under RNTCP(A.Mishra and S.Mishra NTI Bangalore 2007) showed that higher cure rate and conversion rates were achieved due to concrete efforts in the form of strict supervision and monitoring along with motivation of cases health and nonhealth personnel. An evaluation of bacteriological diagnosis of smear positive pulmonary tuberculosis under programme condition in three districts in the context of DOTS implementation was done by Paranasivam, CN Narang(Indian journal of TB 2006) The study revealed an unacceptably high level of false positive in sputum smear microscopy in Wardha district. This could be attributed to the absence of systematic and intensive trainings in smear examination consequent to the non implementation of the DOTS strategy in this district and a high standard of trainings offered in RNTCP. Another study by Gopi PG and Chander sekaran (Indian journal 2006) showed that cure and conversion rates were linearly associated with initial sputum smear grading. High default and death rates were responsible for low cure and conversion. The proportion of patients who required extension of treatment and those who had an unfavourable treatment outcome were significantly higher among patients with 3+ initial smear grading. This reiterates the need to
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pay more attention in motivating these patients to return to regular treatment and sustained commitment in the control of Tuberculosis . The economic burden of TB is especially high due to the number of people infected and the fact that more than 75 percent of TB morbidity and mortality occurs in the most economically active segment of the population, those between 15 and 54 years of age (Ahlburg, 2000). Additionally, there is a vicious cycle between poverty and TB disease. The poor are more likely to contract TB due to crowded living conditions. The probability of infection as well as the probability of developing active TB from this infection is correlated with malnutrition, crowding, poor sanitation, and poor air circulation; these factors are all associated with poverty. Those who develop active TB are then more likely to fall into or remain in poverty due to the economic costs of the illness. There is inadequate diagnosis and treatment among the poor, which leads to more ill-health and death, which ultimately increases poverty. Although TB is not exclusively a disease of the poor, the poor are less likely to seek and receive quality care, and are two to three times more likely to self-medicate than higher income groups. This lack of adequate treatment aggravates the health and economic effects of the disease (Ahlburg, 2000). The health status of the population is particularly important in India, where many people earn their living through physical power. Disease and poor health can push people into extreme poverty, making it impossible for them to pull themselves out of this state1 (Bajpai and Goyal, 2004). Some studies indicate that a third of those who had to borrow or sell assets to meet health care costs fell below the poverty line, and these studies suggest that out of pocket medical costs may push as much as 2.2 percent of the population below the poverty line each year (Gupta, 2005). Much of Indias disease burden is comprised of infant and maternal morbidity and mortality, infectious diseases, and nutritional deficiencies. Many of these problems could be severely reduced through the use of low cost interventions and prevention undertaken by the public health structure of the government (Bajpai and Goyal, 2004). In India, there is a large public health care system, which consists of the provision of care through a network of sub-centers, primary health care centers (PHC), community health centers (CHC), family welfare centers (FWC), and district hospitals. Coverage by government health services varies widely across the states of India, although almost all states were still inadequate according to the specific guidelines set by the Indian government. In addition to the lack of physical infrastructure, there is a severe lack of qualified staff in the health centers. This is a problem particularly in rural areas, where staff recruitment is a serious problem (Bajpai and Goyal, 2004). This leads to health services being severely skewed towards urban areas (Seshadri, 2003). These shortages in the public health care system disproportionately affect the poor, who are the predominant users of primary health care services. The absence of adequate public
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services means that many people either entirely do without medical care or seek expensive and unregulated care in the private sector. Spending in the private sector accounts for almost eighty percent of expenditure on health (Bajpai and Goyal, 2004). Many of the problems with public health services are caused by inadequate funding by the central and state governments, whose expenditure on health (combined) accounts for three percent of government spending, or less than one percent of Indias GDP (Mahal et al., 2002). Governments of other developing nations spend about three percent of their GDP on 14 health, while governments of developed nations spend about five percent of their GDPs (Bajpai and Goyal, 2004). In India, government spending on health is a responsibility of the state and national governments.

Rationale -The purpose of the study is to assess the extent of the objectives of DOTS being achieved. Since RNTCP is an integrated programme, the key challange is to balance the urgent need for rapid expansion of the programme with the equally important need to ensure quality of implementation. There could be situation where RNTCP guidelines may get diluted at some places as already observed in various studies, which may lead to problems and negative influences on the outcome of the programme . Being such a large
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scale programme, there is need for reliable information regarding strengths and weeknesses in the implementation of DOTS both at micro and macro levels, so as to identify areas requiring improvement. It is not enough to view the programme from providers perspective only ,but it is equally important to consider views and experiences of the patients under going treatment .taking into consideration the facts above, a need is felt to review the implementation of RNTCP-DOTS strategy. The present study is an attempt to undertake review of the programme of the RNTCP at the micro level, so as to identify areas requiring strengthening and make suitable recommendations in order to achieve the desired goals of the programme.

General Objective
To study the organisation, implementation and utilization of DOTS in Jammu district.

Specific Objectives
To describe infrastructure facilities and resources available for RNTCPDOTS in Jammu District. To study providers perception regarding DOTS. To analyse the implementation and achievements of DOTS at various levels in the district To ascertain the extent of satisfaction with services provided and problems if any among patients availing treatment under RNTCP. To make necessary recommendations for the improvement of the programme.

MATERIALS AND METHODS:

The details of the methodology adopted for the study is given below: 1. Study designA descriptive study design was used in the study. 2. Study Area17

The study on RNTCP-DOTS Strategy was conducted in DTC Jammu and its TUs, DMCs and DOT Centres. 3. Study populationa. Service providers For obtaining information on operational aspects of the programme and problems faced in implementation , staff members involved in diagnosis and treatment of TB patients at DTC, TUs, DMCs and DOT Centres. Among services providers at these centres the following staff were included: DTO , MO , STS, STLS, TBHV, LTs. b. Beneficiaries- To ascertain the extent of satisfaction and problems faced in availing treatment for TB,beneficiaries were included in the study from DTC and DOT centres. Sampling procedure and Sampling size:Jammu district has 4 Tuberculosis units and 18 DMCs. Selection of DMCs was done as per the RNTCP guidelines for the internal evaluation of the district. A total of 5 DMCs and 10 DOT Centres were selected. A. Service providers- with regard to service providers all staff directly involved in RNTCP at DTC,TU,DMC and DOT centres were included1. DTO -1 2. MO 10 3. STS - 4 4. STLS -3 5. TBHV-4 6. LTs - 8 7. DOT Providers- 10 8. ASHA - 10

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B. TB patients availing treatment The DTC Jammu has four TUs from which proportionate samples of patients was taken. Both pulmonary and EP TB cases were included in the present studies. The reference period from which the patient were selected for the study was 9 months which equivalent to the longest period for which anti TB drugs can be prescribed under RNTCP in any category. C. Patients and their treatment cards- in order to ascertain treatment out come, treatment cards of TB patients were included. D. Observation- Observation was also made to see the selected activities under the programme. For this all TUs , 5 DMCs out of 18 DMCs and 10 DOT centres were included. Activities like sputum examination for diagnosis, DOTS administration , health education , waste management ,record maintenance etc being performed by health workers was observed. Data Collection technique The following techniques for data collection were used. Secondary data Study of Records and Registers TB register of each TU Lab register of each DMC Treatment cards Primary data 1. Interview of TB Patients A total of 50 patients were interviewed using semi structured interview schedule for collecting information on various aspects like accessibility to DOT centres , experiences while availing treatment , extend of satisfaction with treatment etc. 2. Interview of service providers All the health providers who are working under RNTCP i.e a total of 50 were interviewed using semi structured interview schedule. Information collected included duties and responsibilities under RNTCP , problem faced , suggestions for improvement of the programme. 3. Observation of infrastructure and facilities - Observation check list was used to access the physical infrastructure , facilities and supplies at various DOT
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centres and DMCs. This included waiting area for patients availability of medicines , water , electricity , lab facilities , disinfection of bio medical waste etc.

Tools for data collection Interview schedule to elicit the information from TB patients. (Annexure......) Interview schedule for staff (Annexure.....) Observation check list for DMC (Annexure.....) Observation check list for DOT centre (Annexure.....) Observation check list for TU drug store (Annexure.....)

OBSERVATIONS AND FINDINGS-

RNTCP in Jammu DistrictJammu District is one of the 22 districts of the state of Jammu & Kashmir. In the north, Jammu and Udhampur district bound the district; district Samba in the East, while international
20

borders are in south and west. Jammu city is situated on the banks of river Tawi and is the winter capital of J&K state. About 1/4th part of the district is hilly. Most part of Dansal and Purmandal Blocks are hilly while larger part of Akhnoor is hilly. Forest covers about a third of the area of District. Consequently, Jammu consists of difficult and inaccessible areas. Samba is a newly formed district of Jammu province `but from RNTCP point of view, it is still working as Tuberculosis Unit under DTC Jammu.
RNTCP in Jammu District was implemented on 8th April 2004.It is a truly integrated programme, implemented through DTC, TUs, DMCs, DOT Centres. DOTS is the most cost effective way to deal with TB problem through wide spread network for an improved case finding activity coupled with the facility for the treatment of cases found as near to their homes as possible. The WHOs Directly Observed Treatment Short Course Strategy consists of measures to ensure a complete cure and to prevent development and drug resistance. Health workers are trained to directly observe TB patients ingest the anti TB drugs thrice in a week. DOTS also involves the establishment of case detection and monitoring system.

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22

Breakup of Health Units in Distt Jammu

1. District Hospital 1 2. SDH 1 3. Allopathic Dispensary - 14 4. PHGs 35 5. Urban Health Units (Under Medical College) - 1 6. Urban Health Units (Under Heath Deptt.) 14 7. Mobile Unit 1 8. TB centre 1 9. STD/VD clinic 1 10. 11. Railway Hospital 1 Leprosy Hospital 1

DOTS was implemented in District Jammu on 8th April District profile Total Tuberculosis Unit 4 Designated Microscopic Centres 18 DOT centres 281 Break up TU Jammu R.S Pura Population 66,844 4,48,235 DMC 7 4
23

DOT centres 85 69

Akhnoor Samba Total

3,71,470 3,19,212 18,05761

3 4 18

75 52 281

Map of Distt. Jammu

Jyoti Gupta

24

Map of Distt. Jammu

Jyoti Gupta

25

STRUCTURE OF RNTCP AT DISTRICT LEVEL

District Administrator

District Magistrate / District Collector

District Health Services

District Collector CMO and Supporting Staff

Nodal Point for TB Control District TB Centre

DTO, MO-DTC, LT, DEO, Driver, TBHVs

z One / 500,000 ( 250,000 in Hilly / difficult area )

Tuberculosis Unit MO, STS, STLS, LT, TBHV

Hilly / difficult area ) One / 100,000 (50,000 in hilly / difficult area )

Microscopy Centre

MO, Paramedical Staff, LT

DOT Centre

TBHV, DOT Provider (MPW, NGO, PP, ASHA, Community Volunteers)

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ORGANISATION STRUCTURE
DISTRICT TUBERCULOSIS CENTRE JAMMU District Tuberculosis Centre Jammu is the Nodal point for TB Control activities in the district. The building of DTC is located in Chest Disease Hospital Complex, near Govt. Medical College Jammu. The DTO has the overall responsibility of physical and financial management of RNTCP at the district level. The DTO is also responsible for involvement of other sectors in RNTCP and is assisted by one MO. The post of the second MO is lying vacant in DTC. MO in DTC is looking after the OPD. She is sending the Chest Symptomatics to DMC which is a part of DTC only. DTC also has a DOT Centre where patients are given medicines under direct supervisions by DOT Providers ( Jr. Staff Nurse and FMPHW). Drug days for direct observation treatment are Monday, Wednesday and Friday. STAFF POSITION IN DTC

S.No. Designation
1. 2. 3. 4. 5. 6. 7. 8. 9. 10 11. 12. 13. 14. 15. 16. DTO MO TO BCG Team Leader Lab. Tech. Pharm./ Store Keeper X-ray Tech. BCG Tech. TBHV Jr. Staff Nurse FMPHW NO STS STLS DEO P/T Acctt.

No. in Place
1 1 1 1 3 1 2 1 2 1 1 3 1 1 0 1 27

Permanent / Contractual
Permanent Permanent ----do-------do-------do-------do-------do-------do---1(Permanent) 1(Contractual) Permanent ----do-------do---Contractual ----do---------------------------------

17. 18.

SA Accountant

1 1

Permanent ----do----

DISTRICT JAMMU

4 TUs

DTC TU JAMMU R. S. PURA TU

SAMBA TU

AKHNOOR TU

18 DMCs

CHC SAMBA EH VIJAYPUR 28 CHC RAMGARH PHC RAYA

CHC AKHNOOR PHC JOURIAN CHC PALLANWALA

DTC JAMMU GOVT. MEDICAL COLLEGE ASCOMS PHC KOT BHALWAL CHC DANKSAL GANDHI NAGAR HOSPITAL CHC MARH

DTC Jammu is divided into 4 TUs1. TU Samba 2. TU Jammu 3. TU Akhnoor 4. TU R S Pura A team comprising of specifically designated medical officer TB Control (MOTC), Senior Treatment Supervisor (STS) and Senior Tuberculosis Lab Supervisor is based in a CHC/ Sub district hospital. The TU covers a population of about 3-4 lacs and there is one DMC for every 1 lakh population. TU is the nodal point for TB control activities at sub district. MOTC at TU has the over all responsibility of management of RNTCP and is assisted by STS and STLS.

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OPERATIONAL ASPECTS OF RNTCP DOTS

1. Case detection and diagnosis
Sputum microscopy is the primary tool for diagnosing and monitoring of TB patients. Sputum microscopy is done only in Designated Microscopy Centres (DMCs). In district Jammu there are 18 DMCs. Persons with cough for two weeks or more, with or without other symptoms suggested of TB are promptly identified as pulmonary TB suspects and are subjected to sputum smear microscopy for AFB By the medical officers. In all the DMCs there is a full time trained lab technician who fills up the lab forms and gives sputum containers to patients after instructing him how to cough out the sputum. He collects on the spot specimen and gives another container for early morning sample. After collection of sputum staining is done and a report is prepared with proper grading. All the sputum positive results are written in red ink in the lab register. In all the DMCs all the essential consumables including binocular microscope is available. Facilities for running water for the staining purpose are also present in all the DMCs. At the end of every month a summary abstract is completed by every LT. In health centres other than DMCs there is no provision for collection of sputum. Also no sputum slides are being made in PHIs. Patients from these centres are referred to nearest DMC.

2. Categorisation , Registration and initiation of treatment

If the sputum smear examination is positive for AFB , the patients is referred to MO for categorisation of disease (into CAT-1,2 and 3) and TBHV makes home visit to confirm the address of the patient. If the patient is resident of the area he/she is started on anti TB treatment after assigning registration number in TB register of that TU, otherwise patient is referred to respective DOT centre for further case management. The anti TB treatment started after proper health education and motivation. Sputum negative patients are given a course of antibiotic and then sputum examination is repeated. If he does not improve he is referred for chest x ray and other investigations for confirmation of diagnosis.

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3. Treatment regimen followed -

CAT- I : New sputum positive , seriously ill sputum negative and seriously ill extra pulmonary. 2 months-RHZE , 4 months RH (thrice in a week). CAT-II : Retreatment cases 2 months SRHZE , 1 month RHZE , 5 months RHE (thrice in a week) CAT- III : Non seriously ill sputum negative and EP 2 months RHZ , 4 months RH (thrice in a week) R- Rifampicin H- Isoniazide E-Ethambutol S-Streptomycin Z- Pyrazinamide ( GOI 1997 ) All drugs are administered trice weekly for a period of 2/3 months. Patient is asked to swallow the medicines in front of the health worker in Intensive phase. After this repeat sputum examination is done, if found negative continuation phases started. In this phase drugs are provided on weekly basis, the first dose of which is directly supervised. All the entries are made and patients record is maintained by TBHV/DOT provider at DOT centre which is under supervision of STS. MOTC is responsible for managing the treatment unit. Drug Administration During intensive phase thrice in a week patient is given medicine under direct supervision Monday, Wednesday and Friday. If the patient misses taking drugs on a specific day, he can take them next day. The patient must be contacted within one day of missing dose in intensive phase. During continuation phase the first dose of weekly blister should be directly observed. The patient must be contacted within a week of missing weekly collection of drugs.

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Follow upThe follow up of each patient is to be done at 2-3 months and second at 4-5 months and last at the end of the treatment. Two sputum smears are examined each time during follow up. For the patients who need to be transferred from one TU to another, the transfer form is filled and patient is referred to respective areas. 4. DRUGS FOR TB TREATMENT An uninterrupted supply of good quality Anti-TB drugs is one of the five components of DOTS strategy. A strong procurement & logistics management with respect to drugs is essential to strengthen every link in the drug supply chain from manufacturer to patients. There is a unique system of providing drugs in patient wise boxes ( PWB ) which contain drugs for entire duration of Treatment for each category of Patient. Once a patient is started on anti- TB treatment, a box is assigned to that patient, thus ensuring that entire course is available uninterrupted. DRUG MANAGEMENT : a. Selection : The essential drugs used in RNTCP are Rifampicin , Isonized , Ethambutol , Pyrazinamide & Streptomycin. b. Procurement of Drugs : Procurement of anti TB drugs is done both for PWBs as well as loose drugs. In exceptional circumstances few patients may have to be put on NonDOTS regimen. For such patients loose drugs need to be procured. Loose drugs are also required for pediatric patients , adult patients with low body weight & over weight patients. Procurement of anti TB drugs is made through independent agency appointed by the Ministry of Health & Family Welfare, Govt. of India . c. Distribution : Govt. Medical Stores Depot ( GMSDs ) ( at karnal , Mumbai , Kolkata , Chennai, Gawhati & Hyderabad )

State Drug Stores

District TB Centre

Treatment Unit
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d. Storage of Drugs : Establish storage procedure to ensure that drugs & other supplies are o protected from Unauthorized access. o o Protected from heat, light, moisture, dust ,pests & fire. Easy to locate & identify : Drugs stored according to their expiry date with clearly marked & differentiate. Use the FEFO ( First expiry first out) o Maintain of Records : To know that sufficient stock is available at all levels & there is no expiry of drugs. o Maintaining adequate supplies : It is very important to make sure that every health facility in the district has an adequate supply of anti TB drugs. Pts. Must take all their drugs regularly to be cured of TB. Timely initiation if Treatment is not possible if the supply of drugs is inadequate. o Quantity of reserve stocks at each level at the start of quarter Level PHI TU Drug Store DTC Drug Store State Drug Store Reserve Stocks 1-Month 2-Months 3-Months 3-Months

Recording and reporting

Maintenance of accurate records and registers of patients of programme activities and reporting data to the State / Central Unit each quarter is essential for proper monitoring and management of RNTCP. The reporting is done through various periodic reports from different levels of Health System. In Jammu Distt. , DTO is the overall incharge of Tuberculosis Control Activities and answerable to State TB Officer at State Health Directorate. He / She reviews the monthly activity reports of all MOTCs, STLS and STS with in the Distt. during the monthly Distt. level meeting of the said staff. The monthly PHIs reports are also available at these meetings.

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The date of the review is fixed in advance. It is held on 1 st of every month. Minutes of these meetings are also kept by DTO. At TU level reporting and recording is done by MOTC, STS and STLS. Tuberculosis register is kept at Sub-Distt. (TU) level in the Distt. TB treatment cards of the patients are kept in all peripheral health units. A duplicate card is given to the peripheral health functionaries who administer DOT. Patients keep identity card only. Monthly report is prepared every month and submitted to DTC. Quarterly report on case finding, sputum conversion rate of patients who are on treatment and all possible outcomes of smear positive cases of pulmonary TB (Cured, Treatment completed, Failure, Defaulted, Died and Transferred out) is prepared by STS. The STLS is primarily responsible for supervising all the lab. activities including checking 100% of sputum positive slides and at least 10% of sputum negative slides. It is the responsibility of TU to compile the DMC wise reports of sputum examination done, sputum found positive, NSP, sputum negative, patients put on treatment, extra pulmonary cases and submit the report to DTO. At DMC, the responsible staff are MO and LT. Tools at this level will be referral for treatment register, patients treatment card, RNTCP lab. register and supervisor register. MO should meet weekly all the staff involved in RNTCP. He is responsible for compilation of monthly PHI reports and its submission to TU.DTO who compiles the report (4 copies) in respect to all TB units and sends three of them to the STO, The National Tuberculosis Institute Bangalore and to Central TB Division, DGHS Nirman Bhawan New Delhi.

5. Supervision and monitoring

Supervision is a systematic process for increasing the efficiency of health workers by developing their knowledge, perfecting their skills, improving their attitude towards work and increasing their motivationRNTCP has inherent ability to conduct regular supervision and monitoring at all the levels- national, state, district and sub- district. In Jammu District , District Tuberculosis Officer is the overall incharge of Tuberculosis Control Activities and answerable to State Tuberculosis Officer at the State Health Directorate. D.T.O. with the support of M.O. of DTC is responsible for ensuring the quality diagnosis , treatment, logistics and reporting. She is undertaking supervisory visits to all T.Us and Medical Colleges in the Distt. every month and all CHCs and PHCs in the Distt. every quarter. D.T.O. is provided with a govt. vehicle for purpose of supervision. She is maintaining the Tour Diary for keeping the record of supervisory visits. At T.U. Level , MOTC, STS, and STLS are responsible for undertaking supervisory visits to all the PHIs, NGOs and PPs. The MOTC is responsible for supervising the work of TU, STS and STLS in addition to his / her other responsibilities. He has to submit Tour Programme at the begining of the month to D.T.O. and maintains Tour Diary for keeping the record of his

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supervisory visits. He can hire the vehicle for this activity and can claim charges as per RNTCP guidelines from DTC. STLS is responsible for the quality of sputum smear microscopy services provided by DMCs under TU. He is visiting all the DMCs under the TU at least once in a month. STS visits all the PHIs at least once every month he checks whether all the sputum smear positive patients recorded in the TB Lab. register are placed on treatment and register in TB register. He also compares the date in the TB Lab. register with that in the TB register. STS & STLS are provided with a motor bike under RNTCP guidelines for supervisory visits. They also prepare Tour Programme and maintain Tour Diary every month. They also carry supervisory checklist for this activity at DMCs and DOT Centres.

Methodology of Supervision & Frequency of Visits

Category of Supervisor DTO

Methodology of Supervision Interviews MOTC, M.O I/C of PHC / CHC, STLS, LT and DOT Provider, Health personnel of other sectors (NGO, Private) and the person incharge of anti-TB Drugs and consumable storage. Interacts with community and local opinion leaders. Randomly Interviews the patients and community leaders. Inspects records of TU, PHC and CHC and stock of anti- TB Drugs and Lab. consumable. Randomly Checks the microscopy centres and treatment observation centres. Interviews M.O I/C, PHC / CHC Randomly Interviews patients and community leaders. Interacts with community and local opinion leaders. Randomly checks the microscopy centres and DOT Centres. Stock of anti-TB Drugs and Lab. consumables. Interviews Health workers at sub-centres. Inspects Records TB treatment cards and TB registers.
35

No. of Supervisory Visits Visits all TUs every month and all DMCs every quarter. Visits all CHC / PHCs in the Distt. every quarter, one sub-centre from each block PHC area and proportion of DOT Centres every quarter.

MOTC

Visits all DMCs every month and PHCs / CHCs and DOT Centres once every quarter. Conducts supervisory visits 7-days a month.

STS

Visits all PHIs at least once every month and all DOT Centres every quarter.

STLS

Randomly Interviews the patients. Inspects all microscopy centres and Lab. Visits all DMCs once in a records. month.

6. TRAININGS The RNTCP involves many activities, such as Case finding by sputum smear microscopy, Directly Observed Treatment with standardized short course Chemotherapy, Use of Recording & Reporting System, etc.. High quality training is critical to the successful implementation of RNTCP. It is imperative to conduct quality training of all levels of personnel who have TB related responsibilities. In Jammu district, most of the staff looking after Tuberculosis programme in trained but motivation level can still be improved by time to time refresher trainings. 10. Information, Education & Communication (IEC) The stigma associated with TB precludes many from seeking medical help. The patients tend to discontinue treatment after sensing a feeling of well being. There is over reliance on X-ray for diagnosis especially in private sector & unsupervised treatment is offered with non standardized regimens. In order to control TB, there is need for dissemination of information about tuberculosis ( signs & Symptoms ), its cause, detection & treatment there by empowering individuals, families & communities to be responsible for behavioral change to achieve cure of people suffering from tuberculosis.

7. Role of Medical Colleges in RNTCP in Jammu Involvement of Medical Colleges in RNTCP is a high priority in Jammu Distt. Medical College Professors have an important role in TB Control as opinion leaders and trend setters in sustaining the programme by teaching and practicing DOTS & most important of all as role models for practicing Physicians. In Jammu District following Medical Colleges are involved in RNTCP:1. Govt. Medical College, Jammu.
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2.Acharya Sri Chander College of Medical Sciences. Govt. Medical College, Jammu GMC, Jammu is playing a very important role in RNTCP. It is functioning as DMC as well as Dot centre. Since it is a tertiary level Hospital, people have lot of faith in the medical facilities available here. It caters to both rural & urban population in Jammu District. There is a separate Chest Diseases Hospital in Jammu city, where all chest symptomatics prefer to come for diagnosis & treatment. Also there are special wards for indoor patients. Patients in emergencies are referred to CD hospital. They are admitted here & treated with prolongation pouches. There is a well established Microscopy Centre which is performing very well as far as sputum microscopy is concerned. A well trained team of Medical Officer, Lab. tech., TBHV ( DOT provider ) is looking after RNTCP in CD Hospital. Also the Chest Physician posted in CD Hospital are contributing a lot in this programme. Above all Principal medical College who is a Chest physician. He is running a evening chest clinic in the hospital premises to help the chest symptomatics. Acharya Sri Chander College Of Medical Sciences. ( ASCOMS ) ASCOMS is a private Medical college. It also has a DMC & a Treatment centre. RNTCP team comprising of Medical Officer, Lab. Tech., Dot provider ( TBHV ) is working there. Since the medical college is situated away from the city, the patients generally avoid going there. Most of the Doctors in the hospital are trained in RNTCP. Chest physicians working there are also trying their best to improve the outputs / results.

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DTO ( District Tuberculosis officer ) Jammu is overall incharge of the DMC, ASCOMS. She is regularly supervising the DMC work & coordinating with the Doctors of ASCOMS for better results. No. of NGO's and Private Practioners in Jammu Distt.

Initial attempts were made to involve many NGOs and private practioners. 1. St. Josephs Missionary Hospital at Barjani Smailpur 28 pts. 2. Mother Teresa Charitable Trust at New Plots 2 pts. 3. Shivgotra Medicos (Retd. Army Personal) Bahu fort 7 pts. 4. Shivam Medicos Talab Tillo 2 pts. 5. Catholic Social Service Society, Kunjwani 8 pts. (Sh.Nayamat Ali) (Coordinator) 6. (7-8) ASHA Workers.25-pts.have completed their treatment.Only 1 (one) ASHA Worker is presently engaged-3 pts. 7. NGOs and PVT. Practioners in other parts of TU Jammu. 8. Approx. 45-50 ASHA Workers in TU R.S. Pura. 9. ESI Hospital (DOT Centre). 10. Railway Hospital (DOT Centre).

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PERFORMANCE OF THE JAMMU DISTRICT FOR THE LAST FIVE YEARS

The RNTCP has set certain expected levels of performance against which the calculated performance indicators are compared. Case detection rate indicates the extent to which patients with pulmonary smear positive tuberculosis are being treated by the public health system. The expected annualised case detection rate used in the programme planning is 95 NSP per lakh of population of Jammu and kashmir state, of whom at least 70% are expected to be detected in the Government health facilities. From Fig 2, it can be observed that with respect to case detection rate, jammu district is not doing very well. The case detection rate is slowly increasing in the district.

A. CASE FINDING REPORT

NEW SPUTUM POSITIVE CASE DETECTION RATE

YEAR 2005 2006 2007 2008

Population [in lacs] 17.41 18.11 18.69 19.30

No of NSP 618 594 883 957

39

Per lac per year 36 33 47 50

Percentage 38 35 49 52

2009

19.95

1019

53

53

NSP case detection

1200 1019 1000 883 800 957

No of NSP

618 600

594

No of NSP Percentage

400

200 38 0 2005 2006 2007 years 2008 2009 35 49 52 53

RE-TREATMENT CASES All the defaulters, failures and chronic cases, in which the treatment is started again come under Re-Treatment cases. The expected value for is about 30%.

Year

No of ReTreatment cases 136 293 446 473 553

2005 2006 2007 2008 2009

percentage of RT cases out of total sputum positive cases 18 33 34 33 35

40

Retreatment cases
600 553 473 446 No of Re-Treatment cases 293

500

No of retreatment cases

400

300

percentage of RT cases out of total sputum positive cases

200 136 100 18 0 2005 2006 2007 years 2008 2009 33 34 33 35

From the graph ,it can be observed that re-treatment cases are with in the expected value.

SMEAR NEGATIVE PULMONARY CASES(out of total new pulmonary cases)

The detection of smear ve cases also needs improvement for effecting control of TB in the community. There should ideally, be a one to one relationship between the number of new smear positive case sand new smear negative cases. Thisratio should however be never higher than 1:1.2 percentage Year No of NSN

2005 2006 2007 2008 2009

614 748 629 493 578

41

50 56 42 34 36

Smear negative EP
800 700 614 600 748 629

No of NSN

500 400 300 200 100 0 2005 2006 Years 2007 50 56 42

493 No of NSN Percentage

34

2008

EXTRA PULMONARY CASESYear Extra pulmonary cases 349 380 620 564 632 All New percentage of cases(NSP+NSN+NEP) New EP out of all New cases 1581 22 1722 22 2132 29 2014 28 2229 28

2005 2006 2007 2008 2009

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EP Cases
2500 2132 2014 2000 1722 2229

No of EP Cases

1581 1500 EP Cases All new cases 1000 620 500 349 22 0 2005 2006 2007 Years 2008 2009 380 22 29 28 28 564 632 percentage of EP

NEW SPUTUM CONVERSION RATE-

Conversion Rate is the number of smear positive cases which convert from smear positive to smear negative in 2/3 months of treatment out of all smear positive cases registered during the quarter. It should be at least 90%.. A high conversion rate is usually followed by high cure rate, except in special situations ( e.g if there is high mortality due to HIV or a high rate of transfer out.)

Year 2005 2006 2007 2008 2009

No converted 535/618 469/594 770/883 849/957 936/1019

Percentage

87 79 87 89 92

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new sputum conversion rate

95 92 90 89
conversion percentage

87 85

87

conversion rate 80 79

75

70 2005 2006 2007 Years 2008 2009

It can be seen that for each cohort of NSPs detected in the years 2005 2009, the smear conversion rate has been excellent and is around90%.

NSP CURE RATE-

Outcome indicators such as cure , completion, default, failure, death and transfer rates are crucial for assessing the performance of the programme. The cure/success rate achieved for new pulmonary smear-positive cases treated under DOTS is the most important indicator of effectiveness of chemotherapy in treating TB cases and hence success of the programme. Jammu district has achieved excellent success rates of about 86% for most of the cohorts of NSPs detected during 2005-2009.

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NSP CURE RATE-(2005-2009)

YEAR 2005 2006 2007 2008 2009

No cured 449/618 479/594 785/883 850/957 917/1019

NSP Cure Rate
100 90 80 70 73 81 89 89

Percentage

73 81 89 89 90

90

Nsp cure %

60 50 40 30 20 10 0 2005 2006 2007 Years 2008 2009 Cure Rate

PROGRAMME MANAGEMENT REPORTTB SUSPECTS EXAMINEDYEAR POPULATION 2005 17.41 Q1 1433 Q2 1680
45

Q3 1617

Q4 1464

TOTAL 6194

Per lac/qtr 89

2006 2007 2008 2009

18.11 18.69 19.30 19.95

1256 3057 3428 3546

2632 3623 3468 3946

2981 2732 3202 3425

2981 2732 3202 3425

9841 12554 12573 14830

135 167 162 186

Total TB suspects cases

16000 14830 14000 12000 12554 12573

TB Suspect cases

10000 8000 6000 4000 2000 0 2005 6194

9841 TB suspects

2006

2007 years

2008

2009

SPUTUM POSITIVE DIAGNOSEDYEAR 2005 2006 2007 2008 2009 Q1 168 157 407 450 534 Q2 234 409 455 513 529 Q3 266 384 488 379 543 Q4 180 392 365 484 427 TOTAL 848 1342 1715 1826 2033

PATIENTS PUT ON DOTSYEAR 2005 Patients put on DOTS 763/848

46

Percentage

90

2006 2007 2008 2009

852/1342 1543/1715 1704/1826 1864/2033

Patient put on DOT

63 89 93 91

100 90 80 90 89 93 91

Patient put on DOT

70 60 50 40 30 20 10 0 2005 2006 2007 Years 2008 2009 63 Patient put on DOT

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Practices followed by programme personnel under RNTCPTo review the actual practices followed under RNTCP in terms of detailed operational aspects , the various categories of staff were interviewed using semi structured interview schedule.

1. Distribution of staff according to sex and status of appointment. Category Male of staff DTO MO STS STLS TBHV LT DOT Providers ASHA Total 32 10 18 26 14 10 50 8 4 3 4 8 5 1 2 5 1 8 2 8 7 2 4 3 2 3 1 10 4 3 4 8 10 Female Permanent Contractual total

2. Training- All the staff members involved in RNTCP were trained except one MO , who has recently joined. 3 MOs looking after the work of TUs are not trained for MOTC. STS and STLS had training for 15 days and LTs 10 days.TBHV/DOT Providers had undergone training for the period of 10 days. ASHAs working in the field are not at all trained in

48

RNTCP. Most of the staff is working for TB programme for more than 5 years. 3. Duties and responsibilities of the staff- It was started by all staff members interviewed that none of them were provided with written job responsibilities by the higher activities. They had come to know about these from their training as well as day to day experience on job. 4. Address verification- All MOs were asked as how to verify the address of the patient, all of them answered that the address is verified, through home visits by TBHV. As mentioned by TBHVs after obtaining report of the sputum examination of the patient, if found positive for AFB , address is confirmed by home visits. The contact person of the patient, who is any responsible person who knows the patient and can take his responsibility is approached if address can not be verified. 5. Initiation of treatment when asked how the treatment of the TB patient started before confirmation of address, where as four mentioned that treatment can be started if someone responsible guaranties and address is verified later. 6. Drug administration - when asked how do they ensure that patient really consume medicines , all of them said by direct observation. Regarding help from the community volunteers or NGOs , six out of ten DOT Providers said they take the help of NGOs and ASHAs in administering DOTS. For the purpose of home visits they stated for address verification and for tracing the patients in case they default. For the mode of transport, 8 of them replied by their own transport and 2 said by bus. 7. Action taken for seriously ill patients TBHV/DOT Providers were asked as to what they do in case of seriously ill patients who fail to
49

report for drug collection on scheduled date. 2 TBHV;s and 6

DOT

Providers told that it is the familys responsibility to take care of seriously ill and medicines are given to family members for unsupervised therapy.2 of them said that home visits are made and sometimes of ASHA is taken. 8. Material management Drugs and Supply As per information

available from 9 out of 10 MOs all ATT drugs are received as central supply from central TB division. The drugs are available in adequate quantity and in regular supply. Supply of the lab chemicals , reagents and consumables were also reported to be regular and adequate. Only 1 MO reported that he faces problem of irregular supply of drugs and lab consumables as he working in tertiary level health centre and patient load is very high there. All STS , STLS and LTs also reported adequate and regular supply of drugs and lab chemicals but they themselves have to go to the DTC and collect these consumables as there is no provision from district to supply these medicines to their centres. 9. Supervisory visits MOs , STS and STLS were asked about frequency and the nature of supervisory activities perform by them. Only 1 MO reported that he is making 3- 4 visits in his DOT centres per month. All the 4 STS and 3 STLS reported to make 4-8 visits to their centres per month. They are using motor bikes provided to them under RNTCP for this purpose. They are making tour programme and maintaining tour diary which they submit to DTO at the end of the month. They are provided with supervisory checklist. STS said that they check all the treatment cards and records of the patients and also supply of the drugs. They make defaulter visits along with TBHV in case the patient is
50

not retrieved by TBHV alone. All STLS said that they cross check all the positive slides and 10-20% of the negative slides, they also check regularity of supply of lab consumables. They visits all the DMCs at least once in a month. MOs visit DMCs occasionally as reported by all STLS. DTO Jammu is also playing important role in the supervision. She is visiting all the DOT centres in the district regularly and putting forward the reports of her findings to STO. She also mentioned that she is provided with a vehicle for supervision. Medical officers perception regarding satisfaction level in staff & patients. Medical officers were asked about their perception regarding satisfaction among the staff & patients with the implementation of the programme. All of them replied that staff was only partially satisfied with the implementation of the programme. Regarding patients satisfaction, 6 out of four said that patients were partially satisfied. All M.Os mentioned that they were fully aware of the problems faced by patients. They all said that there is no difference in working of regular & contractual staff. Information, Education & Communication All 10 LTs were asked as to what Instructions they give to patients for sputum sample. All said cough deeply. All the MOs, TBHVs & DOT providers mentioned that motivation & health education is provided individually. The detailed health education is provided at the beginning of treatment & is supported by all health workers.

51

When asked regarding IEC in there DOT centres, said that posters are used for conveying messages, whereas MO mentioned about community meetings and health talks. Waste Management: All medical officers & LTs stated that sputum cups & slides are kept in 5% phenol & then disposed off in the hospital bins. Recording & Reporting: This information was collected during interview of service provides as well as during observation of various DOT centres. The TB lab register at all DOT centres in maintained by LT as well as lab forms for sputum are entered by LT. The patients treatment cards & drug records are maintained by DOT provides. All patients maintain their Identity cards but all entries are made by DOT provider/TBHV. The indent register for lab chemicals, reagent & consumables is maintained by all STLS & for drugs , disposal syringes & needles in maintained by all STS. The TB register for each treatment units is maintained by respective STS as well as all entries in it are made by him. All LTs stated that performance reports are sent monthly to STS &

quarterly reports are also being submitted at the end of each quarter. All the STS & STLS stated that monthly reports are submitted to DTO, which are compiled into quarterly reports by Data Entry operator.All medical officers also confirmed that reporting on performance of cases in done monthly by LTS & TBHVs. 4 MOs stated that reports are sent to central TB Division MOHFW & state TB officer. Monitoring of the programme: All MOs mentioned that regular monthly meetings are held between DOTS implementing staff i.e. LTs, TBHVs, STS, STLS & DTO. Regular monthly meetings

52

are also held between DTO & STO. As told by DTO teams from MOHFW & other agencies also visit to review the programme.

Problems faced & suggestions given by staff: Health workers were asked to enumerate the problem faced by them & suggestion for improving the patient care services. Out of 10 LTs, 5LTs said that they did not face any problem. 2 LTs remained silent & rest 3 mentioned few problem: Lab was too small & working space was inadequate. Patients do not give proper sputum samples so smear examination has to be repeated. They also mentioned about heavy work load be cause they also have to do all the routine has lab in the health centres TBHVs told that they face problem during have visits. It was difficult & hectic job to find a house in many localities especially in case of slums. One TBHV mentioned that area covered by him was to big. They also stated that they had to walk a lot to trace a house. Some patients give wrong address because of which patient can not be traced. DOT providers stated that patients prefer taking medicines home rather swallowing them in their presence. In DOT centres, patients bring some local leaders/influential peoples of that area to take medicines at home. Two DOT providers also stated that space provided for the centre is not adequate for administration of DOTS. STS, & STLS also stated problem because of absence of MOTC, in their TUS. They also stated that few health worker do not co-operate with them during field
53

visits. AT few DOT centres there is no permanent DOT provider because of scarcity of man power. They suggested that community volunteers/ASHAS should be involved in activity. Not much suggestion were given by them. MOs stated that refresher training of staff should be done time to time. They also reported scarcity of man power in the fields should be sorted out. MOs also suggested that supervisory staff should act more activity for better performance of the programme. Problems faced & satisfaction with treatment among TB patients. In order to obtain information regarding various problems faced by patients & their satisfaction with services provided, a sample of 60 patients was selected from various DOT centres of Distt. General profile of patients interviewed Category Male No. Cat. I Cat II Cat III 20 12 6 38 Female Total No. 15 3 4 22 No. 35 15 10 60

Category wise distribution = pie chart

54

55

Category & Age

Age < 19 20-29 30-39 40-49 50 & above Total

CAT I 1 5 7 16 6 35

CAT II 0 2 4 6 3 15

CAT III 1 3 2 3 1 10

CAT IV 2 10 13 25 10 60

Out of 60 patients interviewed 38 (63.3%) were male & 22 females (36.7%) As for as age is concerned, max patients lie between 40-49 yrs of age (25 out of 60 patients i.e 42.6% ) Only 2 patients were less than 17 yrs of age. Source of Referral of patients: All respondents were asked from where they were referred to DOTS centre. Out of 60 patients interviewed, 38 patients were referred from various government hospitals & dispensaries in the areas. 6 patients reported to DOT centres on their own and 6 after getting information from neighbours & friends. About 10 patients were referred by private practitioners.

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Source of Referral 1. Private Particulars 2. Govt. Dispensaries 3.Divelty reported 4. Neighbours

No of patients 10 38 6 & 6

friends Total 60

LAB INVESTIGATIONS:- All patients were enquired about the number & types of investigations done for the at DMCs. All 60 patients reported to have got 2 samples of sputum exam done before initiation of treatment. Majority of patient had to make 2-3 visits to get reports of sputum samples & in 3 patients. In about 8 patients X-ray chest FNAC was done in the hospital for the diagnosis. Accessibility to DOT centres Patients were asked about distance travelled by them from their residence & travel time to reach the centre. About 20 patients had to travel 1 km or less to reach DOT centres. 26 patients had to travel to 2-3 km to reach centre & 14 patients had reported to have travelled beyond 5 km to reach the centre for the treatment. Majority of patients reported to reach DOT centres by mini bus.

57

Waiting time at DOTS centre The average waiting time in getting treatment was reported to be 15 to 25 . Patients at DOT centres at secondary & tertiary level hospitals reported that they have to wait for about half an hour. Availability of Medicines All patients were asked if they could obtain all medicines prescribed to the to them. According to all, the anti TB medicines were available for every patient put on DOTS treatment from the centre & were available free of cost in blister packs. Improvement in symptoms from in of Treatment When patients were asked regarding of doses of treatment taken after which there was improvement in their symptoms, majority of then (45 ie 75%) reported improvement in symptoms with 10-12 doses of anti-tuberculosis drugs ie 3-4 weeks of regular treatment. Missed doses during treatment whenasked about number of doses of

treatment they have missed till date, only 4 patients said that they have missed one dose. 2 patient reported too sick as the reason for missed doses, whereas 2 other reported gone out. Attitude of health staff As regards the attitude of DOTS centres health staff patients, 54 (90%) stated it to be fully sympathetic & only 6 had different views of which 3 stated to be rude/unsympathetic. As regards the availability of staff of DOTS centre 59 respondents stated that the staff was present.
58

Health Education: 54 patients said that they were provided. Information about TB and related issues whereas 6 said no information was provided to them. They told that they were advised to cover their face while coughing & not to food & utensils so that other dont get disease from them. Satisfaction in the services available. 56 patients (96.6%) said that they were satisfied with services. However, 3 patients responded by saying as some what satisfied & one even said that he is not satisfied because he has to come from from far off place. When asked about reason for satisfied they said lack of financial burden as these medicine are available free of cost. Also sympathetic attitude of the providers was enumerated as reason for their satisfaction. Problems faced by patient Out 60 patients interviewed, 18 patients (30%) reported to have faced one or more problems. Some of the problems they maintained were: Difficult to come on alternate day Symptoms not improving Wastage of time Owners dont allow to go to centre Long distance to be travelled to reach DOT centre Too week to go to centre Long distance to be travelled to reach DOT centre

59

Findings Based on observation of DOT centre A check list was used in order to obtain information on operational procedure & practices adopted under RNTCP at DOT centres. A total of 10 DOT centres were selected for this purpose and following observations were made: All the patient wise boxes were being marked & maintained for each patient. There was facilties for clean water in all DOT centres. A total of 50 patients were observed for direct observation of treatment & the findings were: Patients physically reported to collect drugs 48/60 = 80% Drugs carried by relatives 12/60 = 20% Medicines swallowed under direct observation 40/48 = 83.5% Medicines carried have by patients = 8/48 = 16.5% All entries were correctly entered & treatment cards were complete:

Home address verification was done in 45 patients. Adequate stock of anti TB drugs was available for Cat I, Cat II & Cat III patients, but not as per RNTCP guidelines. Boxes were stored in safe dry places not exposed to sunlight. Adequate number of disposable syringes, needles & distilled water ampoules for CAT II patients were available only in 2 centers. In Rest 8 DOT centres patients were getting then own disposable syringes.

60

IEC material in from of banners& posters were displayed in all the DOT centres. Health workers were also motivating & giving health education to TB patient so that they adhere to treatment.

Observations at Designated Microscopic CentresA total of 5 DMCs were selected as per RNTCP guidelines for the internal evaluation of the District. A Check list was made and following observations were made All the chest symptomatic from OPD were referred to DMCs where RNTCP trained LT was present who was filling up the lab forms and was giving sputum containers to patients after instructing him how to cough out the sputum. He was collecting on the spot specimen and was giving another container for early morning sample. After collection of sputum staining was done and a report was prepared with proper grading. All the sputum positive results were written in red ink in the lab register. In all the DMCs all the essential consumables including binocular microscope was available. Facilities for running water for the staining purpose were also present in all the DMCs. At the end of every month a summary abstract is completed by every LT.

61

DiscussionAppraisal of any programme is important both at macro land micro levels, the present study has been conducted with the aim of a micro level performance appraisal of the RNTCP in a District the important aspects of the programme like organizational` and operational features, availability of resources, treatment outcome among patients registered as well as experiences and problems among service providers and beneficiaries of services. Since initiation of RNTCP in this district about 6 years have passed and it is assumed that the programme has overcome the likely problems in the initial phase of implementation. For successful implementation of the programme it is essential to have an effective organization with committed staff who are well conversant with the programme objectives and their own role towards its implementation. From the study of the organizational set up, it was evident that the human resource available and their distribution in the different functional units i.e. the Treatment Units and their attached DOTS centres had been quite satisfactory as per the programme guidelines, trained in RNTCP and well experienced in TB control activities. Another strength of the programme in terms of human resource in this District was that on the whole the staffs were aware about their job responsibilities towards the RNTCP even though they were not provided with any written job chart. One of the essential features of RNTCP is the commitment under the programme to ensure a regular, adequate and uninterrupted supply of all anti TB drugs and other supplies including equipment and consumable items for running the programme. One of the parameters for assessment of performance of the TB control programme is its ability to detect maximum number of cases and to put them on
62

regular treatment and thereby achieve best cure rate of over 85% as per the objective of the RNTCP. In this study the different indicators of treatment outcome for the District were calculated for five years i.e. from 2005 to 2009 and it was observed that case detection had been very low in the past but slowly improving. The cure rate achieved for new sputum positive cases treated under DOTS is the most important indicater of effectiveness of chemotherapy in treating TB cases and hence success of the programme. Jammu district has achieved excellent cure rates of about 89%-90% in last 3 years. The Sputum conversion rates at the end of 2/3 months were nearing 90% in last 2 years which is well in comparision with expected levels. With regard to the various qualitative aspects of treatment of patients, the practice in this Distt. was reported to be to initiate treatment only after verification of address of the diagnosed case as already described. Those who are residing outside the area of jurisdiction of the TUs are referred after investigation and diagnosis, to their respective TUs/DOTs centres near to their residential areas. This practice will be useful for all patients registered for treatment at the centre since it will ensure proper follow up of patient as well as default action when required, provided the timely home visit and address verification is done and treatment initiated by the staff. Problems like too large population and area to be covered by staff, inadequate work space for staff particularly for laboratory, patients giving wrong addresses should be taken care of.

For the success of the DOTS strategy adopted under the RNTCP, one of the most essential requirements is to ensure direct observation of treatment taken by the

63

patient for all doses during intensive phase and for the first dose under the continuation phase. One of the disturbing observation made under the present study was that, only about of the patients treatment observed by the investigator were 70% seen to be actually getting treatment under observation by the staff. Among the rest 30% , patients were either represented by their proxy/relatives for collection of medicines home without swallowing the dose in from of the staff. The RNTCP has made a very laudable provision for ensuring treatment by the patients through community involvement where community volunteers and NGOs can be involved for follow up as well as direct observation of treatment wherever, the programme staff have difficulties. ASHAS female community volunteers and female can be considered a valuable help in making this programme a success.

Training of the staff has to be according to the guidelines. The health professionals across all strata , have to be sensitized to proper diagnosis and treatment of all sputum positive cases. Skill based training programme are part of RNTCP strategy. Because of transfers , promotions and retirements , trainings need to be a constant affair.

The success of RNTCP would depend on regular and complete treatment and resultant high cure rate among patients. The patients are adequately informed about the disease and the need for complete treatment through proper health education and programme specific IEC strategy. Patients are well informed and motivated through IEC using interpersonal communication methods, at the time of initiation of treatment but there was no strong evidence for such continued
64

and sustained efforts on the part of the staff during subsequent contacts with the patients during the later part of treatment. Other media of communication like hoardings and posters were seen to be displayed in most of the DOTS centres but there is need for more emphasis on IEC through interpersonal communication to ensure continued motivation of patients to complete the treatment. Being a highly infectious disease, infectious sputum samples are to be handled by the laboratory staff, one of the essential requirements under the programme is proper and hygienic disposal of all such infectious material for the safety of the community and of the personnel handling such materials. On the whole the infrastructural facilities under the programme at the Distt centres were quite satisfactory. Accessibility and approachability of the diagnostic and treatment facilities at convenient locations in easily identifiable manner are the strong features that could be noticed in this study. Few DMCs are working as DOTs centres due to shortage of space & also at few centres LTs administrating the treatment to patient. Though there were few problems related to the lay out and availability of space in some of the DOTS centres, in general there was adequate space for staff as well as waiting space for patients, availability of water and electricity, maintenance of general cleanliness etc. Binocular microscopes were available in all the microscopy centres. It was satisfying to note that generally patients did not have any problem in getting the tests done or in getting the reports as seen from the interview data from patients. There was no shortage of items like drugs or other laboratory reagents reported by any staff, which is to be recognized as a very strong feature of the programme.

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Though DTO, STS and STLS are looking after supervision & monitoring of the RNTCP. Medical officers at the TUs should be made responsible and accountable for the activities so that case detection can be improved in the peripheral areas.

Patients were also by and large satisfied with the services from the centres. However few patients had stated to have faced some kind of problem like difficulty in coming on alternate days for treatment and long distance to travel, financial loss etc. Patients who have to attend centres from their place of work had express difficulty in getting permission could have contributed to the increase default rate only a very small number among the interviewed patients reported to have missed any dose during the treatment. However, those few who missed gave reason like urgent work or gone out etc which gives an impression that they have not clearly realized the significance of uninterrupted treatment which needs to be stressed while motivating the patients. Maintenance of records and submission of monthly and quarterly reported were found to be reasonably good in the DTC, TUs and DOTS centre as per the programme guidelines. Some of the shortcomings observed at the implementation level in DOTS centre could easily be overcome if proper and adequate supervision is being carried out by the concerned staff, it seems that no regular schedule of visits are prepared or followed. Need for special emphasis on more regular and effective supervision is amply evident.

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Conclusions and recommendationsConclusions-

A rapid appraisal of organisation , implementation and utilization of DOTS in Jammu district of Jammu and Kashmir.

General Objective
To study the organisation, implementation and utilization of DOTS in Jammu district.

Specific Objectives
To describe infrastructure facilities and resources available for RNTCPDOTS in Jammu District. To study providers perception regarding DOTS. To analyse the implementation and achievements of DOTS at various levels in the district To ascertain the extent of satisfaction with services provided and problems if any among patients availing treatment under RNTCP. To make necessary recommendations for the improvement of the programme MethodologyThe study was descriptive in nature and was conducted in DTC and DOT Centres of Jammu. The study population comprised of(1) service providers i.e DTO, MOs, STS, STLS, TBHVs, LTs, DOT Providers and ASHAs. (2) Beneficiaries included 60 patients. Observation of selected activities and infrastructure facilities and resources was done using an observation check list in 6 DMCs and 10 DOT Centres. All 50 service providers were interviewed using semi structured interview schedule for collecting information on various aspects like accessibility to DOTS Centres
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experiences while availing treatment ,extent of satisfaction with treatment etc. The records studied were TB registers, TB Lab registers and treatment cards of the patients. Thorough information was obtained on space available, availability of water, electricity, medicines, lab facilities etc. Study findingsThe present study focuses on some of the important aspects of RNTCP-DOTS in Jammu District. RNTCP has been operational since 2004. Profile of the district -

Total Tuberculosis Unit 4 Designated Microscopic Centres 18 DOT centres 281

District Tuberculosis Centre Jammu is the Nodal point for TB Control activities in the district. DTC Jammu is divided into 4 TUs5. TU Samba 6. TU Jammu 7. TU Akhnoor 8. TU R S Pura A team comprising of specifically designated medical officer TB Control (MOTC), Senior Treatment Supervisor (STS) and Senior Tuberculosis Lab Supervisor is based in a CHC/ Sub district hospital.

OPERATIONAL ASPECTS OF RNTCP DOTS

8. Diagnosis and Treatment - Sputum microscopy is the primary tool for diagnosing and monitoring of TB patients. Sputum microscopy is done only in Designated Microscopy Centres (DMCs). In all the DMCs there is a full time trained lab technician who is looking after collection, staining and grading of the smears.

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If the sputum smear examination is positive for AFB , the patients is referred to MO for categorisation of disease (into CAT-1,2 and 3) and TBHV makes home visit to confirm the address of the patient. The anti TB treatment started after proper health education and motivation. During intensive phase thrice in a week patient is given medicine under direct supervision Monday, Wednesday and Friday. During continuation phase the first dose of weekly blister should be directly observed. All the entries are made and patients record is maintained by TBHV/DOT provider at DOT centre which is under supervision of STS. MOTC is responsible for managing the treatment unit. There is a unique system of providing drugs in patient wise boxes ( PWB ) which contain drugs for entire duration of Treatment for each category of Patient. Follow upThe follow up of each patient is to be done at 2-3 months and second at 4-5 months and last at the end of the treatment. Two sputum smears are examined each time during follow up

Waste Management: All medical officers & LTs stated that sputum cups & slides are kept in 5% phenol & then disposed off in the hospital bins. Recording and reporting
In Jammu Distt. , DTO is the overall incharge of Tuberculosis Control Activities and answerable to State TB Officer at State Health Directorate. He / She reviews the monthly activity reports of all MOTCs, STLS and STS with in the Distt. during the monthly Distt. level meeting of the said staff. At TU level reporting and recording is done by MOTC, STS and STLS. Tuberculosis register is kept at Sub-Distt. (TU) level in the Distt only. Monthly report is prepared every month and submitted to DTC. Quarterly report on case finding, sputum conversion rate of patients who are on treatment and all possible outcomes of smear positive cases of pulmonary TB (Cured, Treatment completed, Failure, Defaulted, Died and Transferred out) is prepared by STS. The STLS is primarily responsible for supervising all the lab activities. It is the responsibility of TU to compile the DMC wise reports and submit it to DTO. DTO compiles the report (4 copies) in respect to all TB units and sends three of them to the STO, The National Tuberculosis Institute Bangalore and to Central TB Division, DGHS Nirman Bhawan New Delhi.

9. Supervision and monitoring

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In Jammu District D.T.O. with the support of M.O. of DTC is responsible for ensuring the quality diagnosis , treatment, logistics and reporting. At T.U. Level , MOTC, STS, and STLS are responsible for undertaking supervisory visits to all the PHIs, NGOs and PPs STLS is responsible for the quality of sputum smear microscopy services provided by DMCs under TU. STS visits all the PHIs at least once every month he checks whether all the sputum smear positive patients recorded in the TB Lab. register are placed on treatment and register in TB register. 10. TRAININGS In Jammu district, most of the staff looking after Tuberculosis programme in trained but motivation level can still be improved by time to time refresher training. IECIn order to control TB, there is need for dissemination of information about tuberculosis ( signs & Symptoms ), its cause, detection & treatment there by empowering individuals, families & communities to be responsible for behavioral change to achieve cure of people suffering from tuberculosis.

As per health providers, motivation & health education is provided individually, at the beginning of treatment. In DOT centres, posters are used for conveying messages, whereas MO mentioned about community meetings and health talks.

11.Role of Medical Colleges in RNTCP in Jammu In Jammu District following Medical Colleges are involved in RNTCP:1. Govt. Medical College, Jammu. 2.Acharya Sri Chander College of Medical Sciences. Govt. Medical College, Jammu GMC, Jammu is playing a very important role in RNTCP. It is functioning as DMC as well as DOT centre. Since it is a tertiary level Hospital, people have lot of faith in the medical facilities available here. It caters to both rural & urban population in Jammu District. There is a separate Chest Diseases Hospital in Jammu city,
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where all chest symptomatics prefer to come for diagnosis & treatment. Also there are special wards for indoor patients. Patients in emergencies are referred to CD hospital. They are admitted here & treated with prolongation pouches. ASCOMS is a private Medical college. It also has a DMC & a Treatment centre. RNTCP team comprising of Medical Officer, Lab. Tech., Dot provider ( TBHV ) is working there. Since the medical college is situated away from the city, the patients generally avoid going there. Problems faced & suggestions given by staff: Lab was too small & working space was inadequate heavy work load because they also have to do all the routine has lab in the health centres. TBHVs told that they face problem during have visits. It was difficult & hectic job to find a house in many localities especially in case of slums, area covered by him was to big. DOT providers stated that patients prefer taking medicines home rather swallowing them in their presence.. STS, & STLS also stated problem because of absence of MOTC, in their TUS. AT few DOT centres there is no permanent DOT provider because of scarcity of man power. They suggested that community volunteers/ASHAS should be involved in activity. Problems faced & satisfaction with treatment among TB patients. In order to obtain information regarding various problems faced by patients & their satisfaction with services provided, a sample of 60 patients was selected from various DOT centres of Distt. Out of 60 patients interviewed 38 (63.3%) were male & 22 females (36.7%)

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As for as age is concerned, max patients lie between 40-49 yrs of age (25 out of 60 patients i.e 42.6% ) Source of Referral of patients: Maximum were referred from various government hospitals & dispensaries in the areas. Few patients reported to DOT centres on their own or after getting information from neighbours & friends. LAB INVESTIGATIONS:-. All patients reported to have got 2 samples of sputum exam done before initiation of treatment. Majority of patient had to make 2-3 visits to get reports of sputum samples. Accessibility to DOT centres Maximum patients had to travel to 2-3 km to reach centre & few patients had reported to have travelled beyond 5 km to reach the centre for the treatment. Waiting time at DOTS centre-15 to 25 minutes. Medicines According to all, the anti TB medicines were available for every patient put on DOTS treatment from the centre & were available free of cost in blister packs. Improvement in symptoms from in of Treatment There was improvement in their symptoms, after 10-12 doses of antituberculosis drugs i.e 3-4 weeks of regular treatment. Missed doses during treatment only 4 out of 60 patients said that they have

missed one dose. 2 patient reported too sick as the reason for missed doses, whereas 2 other reported gone out. Attitude of health staff- sympathetic and available during working hours.

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Health Education: Patients said that they were provided information about TB and related issues. They told that they were advised to cover their face while coughing & not to food & utensils so that other dont get disease from them. Satisfaction in the services available. 56 patients (96.6%) said that they were satisfied with services. Problems faced by patient Out 60 patients interviewed, 18 patients (30%) reported to have faced one or more problems. Some of the problems they maintained were: Difficult to come on alternate day Symptoms not improving Wastage of time Owners dont allow to go to centre Long distance to be travelled to reach DOT centre Too week to go to centre Long distance to be travelled to reach DOT centre

The high quality of care and strict adherence to the RNTCP guidelines should be continued and maintained to sustain the smear conversion and success rates already achieved by the State under the programme.

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RECOMMENDATIONSBased on observations and findings made during the study on organisation, implementation and utilisation of RNTCP-DOTS Strategy, it was found that overall performance of the district was satisfactory. But still there is scope for improvement in various components of the programme. PROBLEM 1.Low case detection- The case detection had been low in the district since the implementation of RNTCP. RECOMMENDATIONS To improve the case detection, supervision at DMCs and DOT Centres should be intensified. MOs at the TU levels should be trained for MOTC training and should be held accountable for supervision. All BMOs and MOs at PHCs should stress upon case detection in their monthly meetings. Community volunteers, NGOs, ASHAs and AWWs should also be involved more for this purpose. Training of the staff has to be according to the guidelines. The health professionals across all strata , have to be sensitized to proper diagnosis and treatment of all sputum positive cases. Skill based training programme are part of RNTCP strategy. Because of transfers , promotions and retirements , trainings need to be a constant affair.

2. Trainings- Very few trainings were conducted in the district in last two years.

-3. Inadequate Space and StaffProblem of inadequate space was observed in few centres. Medicines

The DOT centre for administering treatment should be separate from the lab so that patients are observed better
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were kept in the lab and LTs were administering the DOTs because of absence of DOT provider.

while taking medicines. There should be a separate person acting as a DOT provider so that lab technician can concentrate on sputum microscopy.

4.Absence of separate counter for There should be a separate window available for handling over sputum sputum collection sample by patients for lab tests, for the convenience and protection of staff as well as parents. 5.IEC:- Very few activities were observed in the district to educate people regarding sign& symptoms of TB and facilities available under RNTCP IEC activities should be intensified so that people are educated about tuberculosis diseases and about the facilities available under RNTCP. This can increase case detection and adherence to the treatment. The load on the tertiary level hospitals can be decreased if people utilise the services available to them in the peripheral health institution. As we know , a good supervisor is a friend , philosopher and guide for his colleagues and subordinates. Supervision helps to motivate people to perform their best in achieving the goals. Most of the problems have local solution and can be easily resolved by interacting with the workers of health facility. Out of 4 TUs only one TU has MOTC trained in RNTCP and doing supervision. So, training of the MOTCs is essentially required so that they look after the work of RNTCP and help in solving the problems of the staff.
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6.problems of the staff- like too large population and area to be covered by the staff, non-cooperation by peripheral staff. In absence of MOTC the STS and STLS in 3 TUs are facing few problems. The heath providers in the field show negative attitude and dont pay much attention to them. Even the LTs who are permanent , at times dont cooperate thinking that STS and STLS are on contractual basis and junior to them, so they dont have any right to supervise their activities. The MOs who are made in charge to look

after work of RNTCP are so busy in their routine and emergency duties that they hardly find any time for supervisory activities.

7.Role of NGOs and Private Practitioners- very few NGOs and PP are participating in RNTCP

The NGOs and private provider are consider closer to and more trusted by patients and perform an acute role in health promoter in the community. The GOI has developed guideline for NGOs and private sector involvement in TB control Private providers are very accessible to patients and can play a key role in TB control. The first contact of a large proportion of TB Patients is a private practitioner. It has been acknowledged that involving private providers helps to improve both case detection and access to standard services under RNTCP in Jammu.

8.MDR TB-Findings of the district A show quite a number of

lab for sputum culture and should be made

re- sensitivity

treatment cases. Not all patients can operational at the earliest so that afford sputum culture and MDR-TB and patients are diagnosed according to their

sensitivity test.

treated

culture and sensitivity reports.

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9.TB/HIV Collaboration

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Das Gupta, M., Khaleghian, P., and Sarwal, R. (2003). "Governance of CommunicableDisease Control Services," Rep. No. 3100. World Bank, Washington, DC. Deogaonkar, M. (2004). Socio-economic inequality and its effect on healthcare deliveryin India: Inequality and healthcare. Electronic Journal of Sociology. Dholakia, R., and Almeida, J. (1996). "The potential economic benefits of the DOTSstrategy against TB in India." World Health Organization, Geneva . Frieden, T. R., Sterling, T. R., Munsiff, S. S., Watt, C. J., and Dye, C. (2003). Tuberculosis. The Lancet 362, 887-899. Global Alliance for TB Drug Development (2001). "The Economics of TB Drug Development." Global Alliance for TB Drug Development, New York. Gupta, D. (2005). "Covering a billion with DOTS: My Experience with India's Revised TB Control Programme (1998-2004)," Delhi. Understanding Political Incentives for Providing Public Services. The World BankResearch Observer 20, 1-27. Khatri, G. R., and Frieden, T. R. (2002). Controlling Tuberculosis in India. Rajeswari, R., Balasubramanian, R., Muniyandi, M., Geetharamani, S., Thresa, X., andVenkatesan, P. (1999). Socio-economic impact of tuberculosis on patients andfamily in India. International Journal of Tuberculosis and Lung Disease 3, 869Seshadri, S. R. (2003). Constraints to scaling-up health programmes: A comparativestudy of two Indian states. Journal of International Development 15, 101-114. Chandersekran, V.Gopi (2002) Indian journal of Tuberculosis.(2005) Paramasivam and C.N Narang. (Indian journal of Tuberculosis) A.Mishra and S.Mishra NTI Banaglore Bulletin 2007. World Health Organization (2000). "Joint Tuberculosis Programme Review: India." World Health Organization (2003). "Treatment of tuberculosis: guidelines for nationalprogrammes," 3rdWorld Health Organization (2005a). "Global tuberculosis control: surveillance, planningfinancing." World Health Organization, Geneva.
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