Tuberculosis (TB) is a major public health problem in India. India accounts for one-fifth of the global TB incident cases. Each year nearly 2 million people in India develop TB, of which around 0.87 million are infectious cases. It is estimated that annually around 330,000 Indians die due to TB.
Since 1993, the Government of India (GoI) has been implementing the WHO-recommended DOTS strategy via the Revised National Tuberculosis Control Programme (RNTCP). The revised strategy was pilot-tested in 1993 and launched as a national programme in 1997. By March 2006, the programme was implemented nationwide in 633 districts, covering 1114 million (100%) population. Phase II of the RNTCP started from October 2005, which is a step towards achieving the TB-related targets of the Millennium Development Goals. Since 2006, RNTCP is implementing the WHO recommended “Stop TB Strategy”, which in addition to DOTS, addresses all the newer issues and challenges in TB control.
The objectives of RNTCP are:
To achieve and maintain at least 85% cure rate amongst New Smear Positive (NSP) pulmonary TB cases.
To achieve and maintain at least 70% detection of such cases.
The structure of the RNTCP comprises of five levels; National, State, District, Sub-district and Peripheral health institutions. The Central TB Division which is a part of the Directorate General of Health Services, Ministry of Health and Family Welfare (MoH&FW), GoI, is responsible for tuberculosis control at the national level, and is headed by a Deputy Director General (TB).
At the State level, the State Tuberculosis Officer is responsible for planning, training, supervising and monitoring the programme in their respective states. The District TB Officer has the overall responsibility of physical and financial management of RNTCP in the respective districts. An innovation of RNTCP is the creation of sub-district “Tuberculosis Unit” supervisory and monitoring team, for an approximate population of 500,000, (250,000 in tribal and difficult areas), comprising of a designated Medical Officer – TB Control, a Senior Treatment Supervisor and a Senior TB Laboratory Supervisor, based in either a Community Health Centre, Taluk Hospital or Block Primary Health Centre.
RNTCP has established across the country more than 12,000 quality assured designated microscopy centres (DMC) providing sputum microscopy services, each DMC covering roughly a population of 100,000 (50,000 in tribal and difficult areas). Patients are provided directly observed treatment (DOT) by either a health care worker or a community worker/volunteer at hundreds of thousands of sites called DOT-centres. The entire course of anti-TB drugs for individual patients is packaged in a ‘patient wise box’ which simplifies drug logistics, restores the confidence of the patient on the health system and ensures that the patient never interrupts treatment due to want of drugs.
The programme has developed standardised training modules for all categories of staff and documents and guidelines on various aspects of the programme. Based on the consensus between RNTCP and Indian Academy of Pediatrics, the existing RNTCP guidelines for the diagnosis and treatment of pediatric cases have been modified and published. A web based resource centre for Information, Education and Communication has been developed. Researchers are being encouraged to conduct operational research in identified key areas
Consistently since 2002, the expansion of RNTCP has accounted for significant proportion of the additional smear-positive cases reported under DOTS globally. The programme to date has treated about 10 million TB patients, with over 1.5 million registered for treatment in 2008 alone.The programme has achieved a treatment success rate of over 86% in new smear positive cases and the case detection in 2008 was 72%. Death rates under RNTCP have been cut 7-fold compared with those under the previous programme (NTP), from 29% to less than 5% among new smear positive cases. With an approximate 18 additional lives saved per 100 patients treated under RNTCP, the programme has substantially reduced deaths amongst patients treated and saved an estimated over 1.7 million additional lives since its inception.
RNTCP has developed partnerships with a wide range of stake holders. To date more than 2500 NGOs, over 19,000 private practitioners, 267 Medical Colleges and over 150 corporate sector health facilities are involved in the programme. Public-private mix (PPM) DOTS has a significant role in achieving the national objectives of case detection and treatment outcomes. National, Zonal and State task forces have been created for the involvement of the medical colleges in the RNTCP. Significant headway has also been made towards the involvement of the Employees’ State Insurance, Central Government Health Scheme, Railways, Armed Forces, Corporate Sector and other Public Sector Undertakings in the programme. Since 2003, PPM DOTS activities have been ongoing in almost all parts of the country.
Joint TB-HIV activities, in collaboration with the National AIDS Control Organisation were started in 2001, initially in the 6 high HIV prevalent states. These activities were subsequently expanded to 14 states and in 2007 a decision was taken to scale-up to the entire country. For this purpose a National TB/HIV Framework has been developed jointly by both programmes and a Technical Working Group meets regularly to advise both programmes on technical guidelines and related policy issues.
Having successfully expanded DOTS services to the entire country, RNTCP is now scaling-up a plan to offer treatment for patients with multidrug- resistant TB (MDR-TB) at DOTS-Plus sites. RNTCP DOTS-Plus guidelines are an adaptation of the international guidelines on programmatic management of drug resistant TB. In 2007, treatment for MDR-TB patients was started at two sites, one each in Gujarat and Maharashtra. By the end of 2008, 190 MDR-TB patients were on treatment in seven states. RNTCP plans to scale up DOTS Plus services across the country in order to achieve universal coverage by 2012 for all re-treatment cases notified under the programme. One of the important activities in this process is laboratory strengthening for quality assured culture and drug susceptibility testing, including the use of recently recommended newer technology for rapid detection of MDR-TB. The RNTCP has also developed a response plan for the extensively drug resistant TB (XDR-TB) which has also been reported from a few institutions in India. In 2007, a consensus statement on XDR and MDR TB was developed following a meeting of experts in Chennai.
The majority of funding for RNTCP is from the Government of India sources which includes a World Bank credit. The programme is also supported with funds from donor agencies including DFID of UK, the Global Fund and USAID. The Global Drug Facility (GDF) procures about half of the drug requirement of RNTCP using funds from DFID.
WHO is supporting the RNTCP by providing technical assistance through a network of about 90 field level Consultants who work closely with the district and state TB officers. In addition about 10 Consultants provide technical support to the Central TB Division. At the WHO Country Office, five international staff, and one national WHO staff provide technical assistance to the Central TB Division, MoH&FW, GoI. WHO India has provided technical support to the RNTCP in the following major areas:
1. In surveillance, quality assurance, TB/HIV collaboration, reporting and data management and in drugs and logistics management.
2. In the development of the strategy document for the supervision and monitoring of the RNTCP, guidelines for the quality assurance of smear microscopy for diagnosing tuberculosis, concise module on RNTCP for medical practitioners and the training modules on TB/HIV.
3. In the revision of the guidelines and technical modules for all types of staff under RNTCP.
4. In the conducting of the national review meetings of the State TB Officers and field consultants in addition to several other meetings with the partners.
5. In the start-up of MDR-TB management, including in development of the RNTCP DOTS-Plus guidelines, in the development of the GLC application, initiation of services for MDR-TB patients and developing a response plan for addressing XDR-TB.
6. In the strengthening of reference laboratories for quality assured culture and drug susceptibility testing, including testing for first and second line drug susceptibility and evaluation of newer laboratory techniques for the purpose.
7. In organizing national and zonal meetings of the task force for the implementation of RNTCP in the medical colleges.
8. In the preparation of funding proposals and multi-year project implementation plans for securing funds from the World Bank and other funding agencies.
9. In negotiating with funding agencies for anti-TB medicines and financial support to maintain the consultant network.
10. In enhancing the Public-Private Mix (PPM) activities under RNTCP, including the use of the international standards of TB care in involving professional medical associations.
11. Technical support to TB-HIV activities of the RNTCP.
12. In the research activities with Tuberculosis Research Centre, Chennai and with other agencies and in the surveys to assess the impact of different tuberculosis control measures.
13. Technical support to National TB Institute in operational research and impact assessment surveys.
14. In the development of GF proposals and in the monitoring of the implementation of such projects
WHO’s technical assistance to RNTCP is supported through partnerships with DFID and USAID.