The review of the National Tuberculosis Programme
(NTP) of India was carried out in 1992 by a team representing the
Government of India (GOI), the World Health Organization and the
Swedish International Development Agency (SIDA). The purpose of
the review was to evaluate present policies and practices, analyse
their adequacy to reduce the tuberculosis problem and recommend
organizational, technical and administrative measures to improve
the programme. The review team analysed the available documents
including epidemiological data and reports of previous evaluations
of the programme, discussed with officers of major institutions
involved in disease control and in training, and made field visits
in three States (Gujarat, Uttar Pradesh and Tamil Nadu) to assess
the programme at the State, District and Peripheral levels. The
National Tuberculosis Programme (NTP) was formulated in 1962 with
major objectives of finding cases among the self reporting chest
symptomatics, providing effective treatment near their homes, giving
priority to smear positive patients and providing free diagnosis
and treatment facilities. Human and financial resources are provided
by Govt. of India and the States.
Situation Analysis: The constraints and
shortcomings observed in the programme are giving low priority
to NTP in allocation of funds and political commitment, wide gap
between expectations and achievements, no change in the trend of
tuberculosis, and threat of HIV infection aggravating the problem.
The programme is integrated with General Health Services (GHS);
however, the population growth and the proliferation of public health
services has made the districts unwieldy for effective supervision
by a single District TB Centre. The present management structure
at national level requires strengthening, reorganisation and training
at the state level. Improvement in the methods and management of
Case-finding is needed as there is undue dependence on X-ray and
clinical examinations. Standards of carrying out microscopy are
low and laboratories are not well equipped. The treatment regimens
are too many and standard regimens are ineffective and of long duration.
Short Court Chemotherapy (SCC) implementation is very slow. The
drug supplies are occasionally interrupted by lack of timely funding
and of buffer stock. The Health Workers (HWs) are not utilised to
prevent defaulting and to achieve treatment completion. The cure
rate as the main indicator of programme efficiency is not available
due to lack of followup examinations. The recording and reporting
is complex and seriously deficient. Health infrastructure in metropolitan
and urban areas is inadequate. The findings of previous programme
evaluations have not been applied nor has adequate use of the results
of operations research for the improvement of programme has been
made.
However, the basic strengths of the India's TB
Programme are considerable. The objectives on which the programme
was established thirty years ago integration, decentralization,
free services, priority to treatment of infectious cases are still
valid today. They provide a sound revitalization of the national
TB strategy. An updated and strengthened programme can expect to
reduce the magnitude of the problem by about half in each 10-15
years. This will require political commitment, initial investment
and strong leadership.
RECOMMENDATIONS Formulation of an executive
task force at apex level, upgrading the central tuberculosis control
unit in the Directorate to enhance the efficiency and effectiveness
of the NTP. Quality of sputum examination to be improved by multiple
smear examination, ensuring quality of microscope, training and
quality control. Giving priority to smear positive cases, adopting
SCC regimens, establishing criteria of treatment completion and
cure. Ensuring an uninterrupted supply of drugs of good quality,
revise the registration and notification system of NTP and giving
due emphasis to cohort analysis. Policy of decentralization
of treatment services closer to the community. Strengthening of
administrative structure at the sub district level by providing
Medical Officer, Treatment Organizer and Laboratory Supervisor to
facilitate decentralization of supervision and tuberculosis programme.
Development of training capabilities by utilizing state training
facilities, medical colleges, public health institutes and voluntary
agencies. In the light of the recommendations and concerns expressed
by the Central Health Council, a revised strategy for NTP
has been implemented in some selected areas of the country with
the World Bank assistance. Operations Research must be carried out
as an integral part of the revised NTP to evaluate performance and
obtain baseline epidemiological information to measure reduction
in the risk of infection.
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