World Tuberculosis Day: Shouldering the burden
While the Revised National Tuberculosis Programme has attempted to cover a large section of the population, with an element of success, the importance of the private sector in TB control cannot be underestimated. A look at the ground realities on the occasion of World TB Day today.
More than a thousand Indians die every day of tuberculosis (TB). To combat this devastating tragedy, the Government of India introduced the Revised National Tuberculosis Programme (RNTCP) in 1993. On the occasion of World TB Day today, DR. C.P. THAKUR, Union Minister for Health and Family Welfare, shares his views with DR. UMA KRISHNASWAMY, evaluating the programme in terms of not only success and failure but of lessons learnt and the "miles to go" to ease the burden from this eminently curable disease.
Dr. UMA KRISHNASWAMY (U.K.S.):
UNBIASED evaluation at a global level by international experts is that TB control in India and implementation of the Directly Observed Treatment short course (DOTS) strategy via the Revised National Tuberculosis Control Programme (RNTCP) is successful. In your opinion, what are the key elements that have contributed to this?
Dr. C.P. THAKUR (C.P.T): It is true that RNTCP in India has performed at the highest levels. India's RNTCP has undertaken one of the fastest expansions of any TB control programme, with a 25-fold increase in coverage in the last three and a half years, and now covers over 450 million of our country's population. At the same time, it has maintained high quality of patient care, with cure rates of over 80 per cent compared to 30-40 per cent under the previous TB programme. To date, RNTCP has started treatment for over one million patients.
To achieve such success has required many elements. First, there has been a high level of political commitment to the programme. This is demonstrated by the increased budgetary allocations of TB control from Rs. 52 crores in 1996-97 to Rs. 136 crores in 2001-02. This budgetary allocation has allowed for the provision of high quality TB services under RNTCP, with trained staff and diagnostic facilities in place. Stringent enforcement of quality preparatory activities, including technical appraisal of implementing districts prior to the start of service delivery, is an important feature in establishing high quality TB services.
For accessible and quality diagnosis, a microscopy centre is established for every 1,00,000 people and in tribal and hilly areas for every 50,000 people and even for much lesser population depending upon the need. A full-time laboratory technician, trained under RNTCP, and hired on a contractual basis if required, works in each centre.
Training of all staff involved in RNTCP is undertaken via specially developed RNTCP training manuals and modules. The use of standardised training material has eliminated the element of subjectivity in the training courses.
Adequate and uninterrupted supplies of anti-TB drugs have been ensured so that no patient who starts treatment has to discontinue treatment due to drug shortages. Patient-wise boxes have generated a lot of confidence. Delivery of observed treatment has been decentralised and is done as close to the patient as possible, using a wide range of DOTs providers from staff in health facilities, anganwadi workers to community members, including those cured, shopkeepers, teachers and many others.
A cadre of field supervisors, with district and State-level TB officers, regularly undertake supervisory visits to the health facilities. Progress of the programme is continuously monitored and evaluated via a robust reporting system which looks at all parameters from financial monitoring, the patient's progress, logistics, to laboratory and supervisory activities undertaken. Giving feedback on all aspects of the programme is an important mechanism to maintain and improve the services provided.
Finally the presence of a strong Central TB division to guide policy and give technical guidance to the programme has been crucial. Although implementation of the programme follows a carefully laid-out set of norms, flexibility is built into the mechanisms. Recognising and understanding the different problems that States face in implementing the programme has been important. For example, special relaxed norms are included to facilitate effective service provision for tribal and under-served populations. Regular interaction between all levels of staff has led to the creation of a body of committed workers dedicated to TB control activity and who recognise that they are accountable for every patient started on treatment.
Dr. U.K.S.: If the global targets for Tuberculosis control are to be approached, let alone met with, nationwide expansion of the RNTCP by 2005 is essential to make an epidemiological impact on the disease. Is there sufficient political and administrative will at both the Central and State level to give priority to this programme? What are the problems you envisage in expanding coverage nationwide without compromising quality?
Dr. C.P.T.: Following on from my earlier comments, I can state that the highest level of political commitment to the programme continues. This is reflected in the fact that currently a population of 800 million has been approved for RNTCP implementation by 2004 with assistance from the World Bank, DFID and DANIDA. This will ensure complete coverage in 16 States and Union Territories and partial coverage in the rest of the country.
This plan is an ambitious one and presents a major challenge to our health services. Building on the lessons learnt by the successful implementation of the programme earlier, a clear path for the expansion of the programme has been laid out. Careful planning, complete preparation, stringent appraisals and strict monitoring of this process will lead to the initiation of quality services. Regular supervision and monitoring of the services provided will enable the managers to maintain these quality services.
We are in full agreement with the targets set for global TB control and will strive aggressively to achieve them by 2005. We will further intensify our visits to States and help them in preparatory activities, including training. We will not, however, compromise on the quality of care provided to patients. The use of intermittent "Rifampicin" is a double-edged sword. Used correctly and given under direct observation to ensure that the patients completely their treatment, we will cure large numbers of people with TB in India. If badly used, not observed and with patients not completing treatment, problems for the future will be created. We have taken note of the lessons learnt from the National TB programme, as we do not wish to repeat the mistakes of the past.
Dr. U.K.S.: Sustaining nationwide expansion of the programme will call for decentralisation. The Constitution has listed "health" as a State subject and functional decentralisation has been the general norm in health matters. However, there are some who perceived the RNTCP as a vertical health programme, which has passed the State level to function directly at district level. Is there substance in this criticism? What plans does the Government have to strengthen State capacity to assume increasing responsibility for programme management and monitoring? What are the specific provisions to pre-empt counter-productive factors that may result from decentralisation?
Dr. C.P.T.: In the early stages, prior to the State taking on full responsibility for the programme, there was a great need for strengthening the State level, which included the establishment of State TB Control Societies. However, we could not wait for implementation of the programme, until all of this had happened at the State level. It is, therefore, true that in the early stages of implementation, much of its management was undertaken by the Central level, directly with the district, but at the same time, parallel activities to strengthen and build capacity at the State level were undertaken. State level officers were also trained in management and financial processes. Transfer of skills to State level officers is an important feature of field visits of Central level officers to the States.
There is a gradual phased decentralisation of ownership and accountability of programme implementation from the Central to State level. Already 21 State TB Control Societies have been released funds from the Central level and are being disbursed to the respective District TB Control Societies. Powers for sanction/appointment of contractual staff like the medical officer, TB-HV and LT have now been vested with the State Society. Six States have already taken up the responsibility of drug distribution to the districts and many others are being strengthened. More States are now assuming direct responsibility for monitoring and supervision of the work done by the District TB Control Societies.
Dr.U.K.S.: It is understood that while the Government advocates the DOTs strategy via the medium of the RNTCP and is labouring to bring the benefits to the country, many government health facilities in organisations such as the Railways, the armed forces, the CGHS, even TB hospitals in some States and districts where the RNTCP is functioning, do not participate. This lack of participation extends not merely to the practice of DOTs, but also to using treatment regimes backed by evidence-based medicine. How would the Ministry of Health and Family Welfare address the problem?
Dr. C.P.T.: Greater involvement of the Railways, the armed forces, and the CGHS and TB hospitals in RNCTP urgently needs to be pursued. There have been many CME sessions and others interactions with these facilities at the Central and State levels. There is local and focal involvement of such facilities in the RNTCP.
An important workshop involving representatives of leading medical colleges was held in 1997. This was repeated with further workshops held very recently at NTI, Bangalore and AIIMS, Delhi. To date, medical colleges in over 60 per cent of RNCTP implementing areas are involved in RNCTP activities. In the process, the capacity of the medical colleges to provide quality TB care is strengthened by the establishment of microscopy and treatment centres within the respective institution and wherever required even resource persons are also being provided.
Dr. U.K.S.: The first point of contact for more than 30 per cent of patients with TB in India is the private practitioner. With 80 per cent of all qualified doctors belonging to the private sector, it has been recognised that there is a largely untapped reservoir with the potential to support the RNTCP. However, many private practitioners perceive the RNTCP as rigid and bureaucratic and are wary of involvement. What can be done to address these very real concerns of the busy private practitioner and involve him in a large scale?
Dr. C.P.T.: In recent years, there has been a visible and palpable change in the perception of RNTCP and the behaviour towards the programme amongst private practitioners. A Guide for Practising Physicians, which is specifically aimed at private practitioners, has been widely distributed. Much effort has gone into numerous CME sessions and other interactions with private practitioners throughout the country. Today large numbers of private practitioners are involved in RNTCP activities, either individually or through such august bodies as the IMA and DMA. A policy document on the involvement of private practitioners in RNTCP activities is likely to be finalised soon.
The draft document was developed in partnership with private practitioners, through a process of consultation at a workshop held in Delhi and attended by leading private practitioners.
I would agree that the RNTCP is rigid in one respect and that is in its goal of ensuring that all TB patients receive the high quality of healthcare that they need and deserve, and are cured of their disease.
I hope that all medical practitioners, both in the public or private sector, shall work towards this goal and that RNTCP and the private sector can enjoy a fruitful collaboration in serving the TB patients of our country.
Dr. Uma Krishnaswamy is a consultant surgeon at the Apollo Hospitals, Chennai, with an exclusive interest in breast diseases and a special commitment to women's health. She is the first and only Asian woman to be appointed as examiner at the Royal College of Surgeons, Edinburgh.
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