Revised National TB Control Programme (RNTCP)

PPM DOTS in RNTCP

Central TB Division, Ministry of Health and Family Welfare Government of India

Problem of TB in India
Incidence of TB disease: 1.8 million new TB cases annually (0.8 million new infectious cases) Prevalence of TB disease: 3.8 million bacteriologically positive (2000) Deaths: about 370,000 deaths due to TB each year TB/HIV: ~2.5 million people with HIV;
About 5% of TB patients estimated to be HIV positive

MDR-TB in new TB cases 3% Substantial socio- economic impact

Population covered (millions)

1000 1200

Population in India covered under DOTS and Total Tuberculosis Patients put on treatment each quarter

200

400

600

800

0 Qtr1-94 Qtr3-94 Qtr1-95 Qtr3-95 Qtr1-96 Qtr3-96 Qtr1-97 Qtr3-97 Qtr1-98 Qtr3-98 Qtr1-99 Qtr3-99 Qtr1-00 Qtr3-00 Qtr1-01 Qtr3-01 Qtr1-02 Qtr3-02 Qtr1-03 Qtr3-03 Qtr1-04 Qtr3-04 Qtr1-05 Qtr3-05 Qtr1-06 Qtr3-06 Qtr1-07 Qtr3-07

Total patients treated Population coverage(in millions)

Quarter/Year

300000

350000

400000

450000

200000

250000

50000

100000

Total patients treated

150000

346794

Annualized New Smear-Positive Case Detection Rate and Treatment Success Rate in DOTS areas, 1999-2007
100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Qtr1-99 Qtr2-99 Qtr3-99 Qtr4-99 Qtr1-00 Qtr2-00 Qtr3-00 Qtr4-00 Qtr1-01 Qtr2-01 Qtr3-01 Qtr4-01 Qtr1-02 Qtr2-02 Qtr3-02 Qtr4-02 Qtr1-03 Qtr2-03 Qtr3-03 Qtr4-03 Qtr1-04 Qtr2-04 Qtr3-04 Qtr4-04 Qtr1-05 Qtr2-05 Qtr3-05 Qtr4-05 Qtr1-06 Qtr2-06 Qtr3-06 Qtr4-06 Qtr1-07 Qtr2-07 Qtr3-07 Qtr4-07

Annualised New S+ve CDR

Success rate

Population projected from 2001 census Estimated no. of NSP cases - 75/100,000 population per year (based on recent ARTI report)

RNTCP: Major milestones in PPM DOTS

Year
1993 1995 1997 2000-2003 2001 2002 2002 2002-2003 2003 2003-2004 2004 2005 2007 RNTCP started in pilot districts PPM model started in Hyderabad (NGO Hospital) National consensus conference of Medical Colleges PPM models in Delhi, Kannur, Kollam, Mumbai, Tea-gardens of north-east Schemes for involvement of NGOs in RNTCP published Schemes for involvement of Private Practitioners (PP) in RNTCP published National workshop of medical colleges: seven nodal centres identified PPM activities initiated in all the RNTCP states Intensified PPM scaling up began in 12 urban sites Initiatives to involve other Government Departments, Public Sector Undertakings Declaration by national IMA to support RNTCP IAP guidelines, Urban DOTS GFATM projects, expansion of intensified PPM 17,000 private practitioners, 250 Medical colleges, 2500 NGOs and 150 corporate houses involved

Milestones

The New Global Strategy to Stop TB

Public-Private Mix (PPM) DOTS

PPM DOTS is a strategy to diagnose and treat TB patients reporting to all sectors of health care under DOTS strategy through a mix of different types of health care service providers PPM DOTS has been defined by WHO as strategies that link all entities within the private and public sectors (including health providers in other governmental ministries) to the national TB programme for DOTS expansion.

ISTC
Focuses on TB care as well as control Supported by a broad international consensus Presents an evidence base Applies to all practitioners and is more relevant to the private sector Serves as a focus of a global campaign to improve TB care and control

Health care providers in India

Ministry of health Directorate of health (RNTCP, primary health care) Directorate of Medical education (Medical Colleges) Other Ministries Railways Employees State Insurance Mining Coal Steel Ports Prisons Armed forces Non-Government NGOs Private hospitals Corporate industries Private practitioners Traditional practitioners

Roles of public and private sectors in PPM DOTS

Public sector
Provides training/supervision drugs/supplies/honorariu m Notifies TB cases Retrieves patients who interrupt treatment

Other sectors
Refer/Diagnose/treat TB cases Inform public sector about
TB patients/interruption of treatment

Follow RNTCP guidelines

NGO/PP guidelines

Achievements in PPM
3000 NGOs involved under RNTCP ~17,000 Pvt. practitioners involved under RNTCP 261 Medical Colleges following DOTS strategy 150 Corporate Houses participating in RNTCP Involvement of professional bodies
IAP involved in development of Pediatric guidelines 2005 IMA actively collaborating in 167 districts/ 6 states under Rd 6 GFATM Project Indian Medical Professional Association Coalition against TB (IMPACT) established in March 2007

Intensified PPM DOTS sites

14 intensified PPM sites
Pilot Site Ahmedabad Bangalore Bhopal Bhubaneswar Chandigarh Chennai Delhi Jaipur Kolkata Lucknow Patna Pune Ranchi Thiruvanthapura m State Gujarat Karnataka Madhya Pradesh Orissa Chandigarh Tamil Nadu Delhi Rajasthan West Bengal Uttar Pradesh Bihar Maharashtra Jharkhand
* Additional sites

Kerela

14 intensified urban PPM districts( 3rd qtr 2006 to 2nd qtr 2007): Summary of Contribution by different health sectors
100% 90% 80% 70% 60% 50% 40% 71.8% 30% 20% 10% 0% 61.2% 61.9% 64.6% 4.8% 3.6% 3.5%

5.8%
5.2% 0.2% 2.5%

7.2%
0.2%

7.0%
6.5% 0.4% 18.0%

11.5%
8.6% 5.9% 0.3% 1.8%

25.7%

24.5%

TB suspects referred

All S+ cases diagnosed N=49674

New S+ cases detection N=26321

No. of Patients provided DOT N=76028

N=35658
Health dept

Govt, other than health

Medical Colleges

Corporate

Private

NGO

Initiatives to Involve Medical Colleges

Medical Colleges as RNTCP Nodal centres

Consensus conference held 1997

JAMMU & KASHMIR HIMACHAL PRADESH

Workshop of professors 2001 Workshops in States / Medical Colleges from 2002 onwards National/Zonal/State Task MC

Chandigarh

DELHI

PUNJAB

North Zone HARYANA

# AIIMS,Delhi
RAJASTHAN#
Jaipur

UTTARANCHAL

ARUNACHAL PRADESH SIKKIM

UTTAR PRADESH BIHAR

North-East Zone
Guwahati ASSAM

MEGHALAYA TRIPURA
Kolkata

NAGALAND

West Zone
GUJARAT MADHYA PRADESH

East Zone #

JHARKHAND WEST BENGAL

MANIPUR MIZORAM

CHHATISGARH ORISSA D&N HAVELI

Mumbai

# MAHARASHTRA
ANDHRA PRADESH GOA

Forces created Core Committees in MCs

South Zone
KARNATAKA

# Vellore PONDICHERRY

A&N ISLANDS

LAKSHADWEEP KERALA

TAMIL NADU

RG Kar Medical College, Calcutta Lokmanya Tilak Municipal Medical College and Hospital, Mumbai SMS Medical College, Jaipur All India Institute of Medical Sciences, N Delhi Post Graduate Institute of Medical Education and Research, Chandigarh Christian Medical College, Vellore, Tamil Nadu Guwahati Medical College, Guwahati, Assam

PPM DOTS Systematic process in involvement

Sensitization of administrators and opinion leaders Orientation of RNTCP staff on PPM DOTS Listing of PPM health care providers Identification/verification of PPM facility Sensitisation of PPM providers Training of PPM providers Signing of RNTCP schemes (Memorandum of UnderstandingMoU)

Start of service delivery

Tools for PPM DOTS

RNTCP guidelines for the involvement of NGOs (2001)

RNTCP guidelines for the involvement of private practitioners (2002)

RNTCP PPM DOTS advocacy kit (2005)

Training module for private medical practitioners

Concise module 6 hours training

1 day X 6 hours 2 days X 3 hours 3 days X 2 hours

Involvement of NGOs in RNTCP

There are 5 Schemes for collaboration with NGOs
Scheme 1- Health education & community outreach Scheme 2- Provision of DOT Scheme 3- In-hospital care for TB disease Scheme 4- Microscopy & Treatment centre Scheme 5- TB unit model

PP schemes
1. Referral services 2. Provision of Directly Observed Therapy 3a. Designated Paid MC microscopy only. 3b. Designated Paid MC microscopy and treatment. 4a. Designated MC microscopy only. 4b. Designated MC microscopy and treatment.

NGO Involvement in RNTCP in India (year wise)

NGO 2500 2046 2000

2263

1500

1222

1000 512 500 150 0 2001 2002 2003 2004 2005 2006 300

PP Involvement in RNTCP in India (year wise)

PP 16000 14000 12000 10000 8000 6000 4000 2000 0 2001 2002 2003 2004 2005 2006 500 900 1500 5518 10714 14674

300 264 250 261 238 214 200

State*-wise distribution of NGOs (3rd qtr 2007)

No of NGOs

207

166 150 131 114 100 105 98

92 69 67 63 61 57 56

50

0 Tamil N adu Punjab Rajasthan Guj arat Bihar Delhi Karnataka Wes t Bengal Manipu r Kerala Ut ta r Pradesh Jharkhand Maharashtra An dhra Pradesh Assam Oris sa Madhya Pradesh

*Only states with more than 50 NGOs involved are presented in the slide

State*-wise distribution of PPs (3rd qtr 2007)

5000 4736 4307 4500

4000

No of PPs

3500

3000

2500

2000 1385 1006 1000 972 730 686 469 500 391 353 346 305 280 256 231

1500

195

169

0 Tamil Nadu Haryana Punjab Karnataka Rajasthan Gujarat Kerala West Bengal Uttar Pradesh Maharashtra Madhya Pradesh Andhra Pradesh Chhatisgarh Chandigarh Assam Bihar Delhi

*Only states with more than 150 PPs involved are presented in the slide

Challenges - PPM DOTS

Public sector related
Lack of interest / experience in dealing with other sectors Lack of faith in the capacity of private sector

Private practitioner related

Large and unorganized private sector Lack of faith in Public sector health programmes Low priority for carrying out public health programmes

Patient related
Contradicting information from health sectors/systems Lack of trust in the quality of care provided by public sector Issues of stigma and confidentiality