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REVIEW OF NATIONAL TUBERCULOSIS PROGRAMME |
Indian Council of Medical Research, New Delhi: Report
of ICMR Expert Committee 1975 |
In 1975 recognising the importance of the TB problem,
Govt. of India, Ministry of Health & FW, on suggestion of TB
Association of India, requested ICMR to constitute an Assessment
Committee who should evaluate the National Tuberculosis Programme
(NTP) and submit a report. A committee consisting of five members
reviewed the NTP in terms of i) aims & objectives of the programme,
ii) implementation and iii) performance at various levels. Its shortcomings
and various factors responsible were identified. Recommendations
to improve the functioning of NTP in all the aspects were suggested.
The country was divided into 5 zones; south, west, centre, north
and east. Two District TB Centres (DTCs) from each zone were selected
for the study. The data was collected by posting proformas to all
the State and Union Territories and by visits of the expert committee
members in groups to different regions in the country. The members
obtained information from state headquarters, DTC, Primary Health
Centre (PHC) and villages.
The committee observed that the general pattern
of the District TB Programme (DTP) does not require any change;
however, it requires strengthening in many ways. The performance
of the DTC and Peripheral Health Institutions (PHIs) was found to
be far from satisfactory in terms of Case-finding, case holding
and BCG vaccination. Since the implementation and supervision of
the programme was the responsibility of the State and which were
found to be the weakest components of the programme, it was strongly
felt by the committee that the programme should be made a truly
national programme by making it centrally sponsored for the
next 10 15 years and the centre should exert direct control over
the programme instead of being left to the state for administering
it. The committee observed that the programme has not been implemented
in 57 districts in 15 States especially in Bihar where out of 31
districts only in 3 districts the programme has been implemented.
Utmost priority should be given to implement the programme in the
remaining districts especially in Bihar. The integration of programme
with the General Health Services has not been satisfactory thus
leading to poor functioning of Peripheral Health Institutions (PHIs).
The poor performance of DTP was mainly due to limited contribution
by the PHIs. The other shortfalls observed by the programme were
lack of adequate supervision and control by the State TB Officer
(STO), District TB Officer (DTO). Most of the centres including
DTC were mainly serving the patients of the town in which they were
situated. Thus, a large part of the rural area was not covered by
the programme. The drug supply was adequate throughout the country
except SM & PAS in some states where doctors were fond of using
SM for every patient and preferred PAS to Thioacetazone as standard
companion drug. There was shortage of MMR films and lab reagents
in many of the DTCs. Equipments like MMR, microscopes, and vehicles
were out of order for long periods for want of maintenance facilities.
It was recommended that the Central Government should have equipment
maintenance organisation and should be responsible for supply of
the drugs, equipments, films and maintenance of the equipments.
The status of the Tuberculosis Adviser should be of the rank of
Deputy Director General, State TB Officer that of Deputy Director,
Health Services and the DTO that of the DHO/DMO. There should be
5 Regional Centres with a Deputy Director In charge, supervisory
staff and adequate funds. The functions of the Regional Centres
will be to exercise supervisory control over the programme in the
region. BCG vaccination coverage in the eligible population of 0
19 years age was found to be 10%. It was decided to change the strategy
of BCG from mass approach to the integrated one i.e., with immunisation
programme, for effective coverage. It is desirable to have periodic
evaluation of the NTP. Therefore, there should be a permanent
evaluation cell at the centre. There should be one TB worker
and one microscopist exclusively for tuberculosis work at every
PHC. There should be active community participation in the villages.
The village headman and teachers should give adequate publicity
for sputum examination and regular treatment. The TB workers at
all levels should be debarred from private practice and should be
given suitable non- practicing allowance. Active involvement of
other governmental bodies like ESI, Army Health Services, CGHS,
Railways etc., in the tuberculosis control by providing Case-finding
and treatment facilities to all their beneficiaries and eligible
patients as per the programme recommendation. Of the five State
TB Demonstration Centres the work was found satisfactory only in
Nagpur. Some training activity was going on there. Lack of political
will and all pervading human apathy was visible at all levels. The
committee felt that a strong 'political will' to give due
priority to the programme was required.
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KEY WORDS: EVALUATION, NTP, PERFORMANCE. |
171 |
IN DEPTH STUDY ON NATIONAL TUBERCULOSIS PROGRAMME
OF INDIA, INSTITUTE OF COMMUNICATION, OPERATIONS RESEARCH & COMMUNITY
INVOLVEMENT, BANGALORE, 1988 |
The current National Tuberculosis Programme (NTP)
was evolved by the NTI, Bangalore in 1962 after conducting a series
of Epidemiological, Sociological and Operational Studies. The programme
is integrated with the General Health Services (GHS). In spite of
its sound conceptual and structural foundation, the programme performance
was below expectation. Government of India had evaluated the reasons
of low performance through a study group constituted by Indian Council
of Medical Research (ICMR), in 1975 but the programme did not improve
either due to non-implementation of the recommendations of the ICMR
committee or they were not effective. The Institute of Communication,
Operations Research And Community Involvement (ICORCI), an independent
agency was asked by the Government of India to have an in depth
evaluation of NTP. The terms of reference for this evaluation
were to review the Objectives, Implementations & Expectations
of the NTP along with various factors responsible for short fall
and give recommendations to improve its performance. The evaluation
was generally through routine quarterly reports received by NTI
and information collected on the spot during the actual field visits
made by the multi disciplinary expert group of ICORCI. A total of
five states were selected. From among the total districts of these
states, nine districts were picked up by composite index methodology
and from each district, two PHCs were selected on the basis of performance.
OBSERVATIONS: About 15% of the districts
are still without DTP. There was an increase of X-ray examinations
per DTP by 1.4 times from 1981 to 1987, the percentage contribution
of PHIs to new sputum examination increased from 34 in 1981 to 72
in 1987 leading to 1.44 increase in diagnosis of cases. Sputum positivity
rate decreased from 13.6 in 1978 to 6.7 in 1987. The percentage
contribution by PHI in case detection increased from 35 in 1981
to 40 in 1987. Number of suspect cases increased 1.8 times in 1987.
There were wide variations in the X-ray positivity rates between
the states, throwing doubt about the quality of X-ray reading. Suspect
cases form 78% of all types of Tuberculosis cases diagnosed in 1987.
This was much higher than the expected 43% according to NTI studies
and indicates considerable over-diagnosis of suspect cases under
NTP. From 1986 only 27% of Tuberculosis patients had made 12 or
more monthly collections of Anti-TB drugs. It is a matter of serious
concern and the reasons have to be investigated. In 1987, only 27%
of the DTPs had a full DTC team and only 65% had DTC vehicle. This
indicates deterioration in supervision. The other factors
like lack of NTI training of DTC key personnel, Communication,
Health Education, Community Involvement and contradictory instructions
from the DTP manuals, central & state guidelines etc., influence
the performance of the programme adversely. Most of the medical
officers of the PHC wanted integration to continue. They only wanted
that the additional inputs may be provided.
RECOMMENDATIONS: Most of the recommendations
given are for improvement of the system which is essential for the
success of NTP. Some specific recommendations for NTP are also given.
Integration of health programme may be effected at district and
state levels in a phased manner. It would be desirable to have integration
with the central level also with one Director General of Health
Services monitoring all programmes in one region of the country.
A common budget for all health programmes/activities will solve
many of the problems and will be in accordance with the principles
of integration. Develop a proper two way referral system
covering all programmes and activities. Orientation training
may be given to all officers regarding budgeting, administration,
monitoring and technical aspects. A vehicle pool may be maintained
at the district level under the control of DCMO and monitored by
CMO. The Central Government may supply microscopes of good
quality instead of providing funds. Working facilities at DTCs and
PHCs may be reviewed periodically to ensure good working conditions
for efficient functioning. Local level recruitments may be made
for Health Assistants and Health Workers. A careful review of the
reasons for indiscipline, particularly at PHC level may be made
before the situation deteriorates further. The entire staff structure
and recruitment may be reviewed to provide promotional opportunities
to all categories of staff. All suspect cases may be put under observation
as per WHO recommendations instead of straight away giving them
anti TB treatment for long periods. Sputum collection by Health
Workers may be re introduced. Reasons for deviation from DTP manuals
may be investigated, particularly in STCs which are required to
train the staff as well as supervise the DTPs. Short Course Chemotherapy
may be extended to all DTPs in the country. Steps may be taken to
ensure that follow up examinations are carried out regularly and
the results recorded on treatment cards. A drug testing laboratory
may be set up in each state as proposed for the VIII plan. Procurement
of drugs may be made only from reputed firms. In order to have a
reliable monitoring, sample checks have to be carried out
to ensure the validity of the records and reports. Targets for NTP
may be withdrawn, particularly those regarding case detection to
avoid over diagnosis. A monitoring and evaluation cell headed by
a statistician may be created under the CMO to cater the needs of
all programmes. The recommendations made for improvement may be
introduced only after proper testing by field trials following operations
research methodology. Changes introduced on adhoc basis may create
more problems than are solved.
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KEY WORDS: CONTROL PROGRAMME, PERFORMANCE, EVALUATION. |
172 |
TUBERCULOSIS PROGRAMME REVIEW INDIA, 1992 |
World Health Organization, Geneva, 1992: |
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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KEY WORDS: REVISED STRATEGY, CONTROL PROGRAMME,
PERFORMANCE, EVALUATION, SITUATION ANALYSIS. |
175 |
A COMPARISON OF PERFORMANCE OF X-RAY CENTRES, MICROSCOPY
CENTRES & REFERRING CENTRES UNDER DISTRICT TUBERCULOSIS PROGRAMME |
R Rajalakshmi & MV Jaigopal: Indian J Tub 1995,
42, 215-20. |
District Tuberculosis Programme (DTP) was formulated
in 1962 with one of the objectives of diagnosing maximum number
of tuberculosis patients. The rural health institutions implemented
as Peripheral Health Institutions (PHIs) are expected to play a
major role. The PHIs according to the type of facilities available,
are classified into X-ray Centres (XCs), Microscopy Centres (MCs)
and Referring Centres (RCs). While all centres provide treatment,
XCs offer chest X-ray and sputum microscopy examination; MCs offer
only sputum microscopy and from RCs sputum slides are prepared and
referred for further examination to DTC/XCs/MCs. The performance
of DTP activities at PHIs are collectively reported. Hence, it was
worth studying categorywise performance of PHIs, which may help
in developing strategy for improvement in the performance of the
National Tuberculosis Programme.
OBSERVATIONS : DTP is operational in 390
(89%), out of the 438 districts in the country. Of the 17,850 implemented
PHIs, 2390 (13.7%), 8717 (48.8%) and 6740 (37.8%) are functioning
as XCs, MCs and RCs respectively. In all, 208 DTP reports for October
to December 1993 quarter received at National Tuberculosis Institute,
were analysed. Reporting efficiency of XCs, & MCs was 85%, whereas
of RCs, 54%. Of the 33.1 million self reporting outpatients belonging
to various PHIs, 35% attended XCs, 43% MCs and 22% RCs. Of the total
sputum examinations performed during the study period, XCs examined
39%, MCs 52% and RCs 9%. Selection of chest symptomatics worked
out to 1.8% for XCs, 2.0% for MCs and 0.7% for RCs. Out of the total
28,654 smear positive cases diagnosed, 56% were detected by XCs,
37% by MCs and only 7% by RCs. It is seen that XCs diagnosed 56%
of the total cases by doing 39% of the total sputum examinations.
The sputum positivity rate at XCs is 7.8% which is almost double
that of 3.8% at the MCs and 4.4% at RCs.
Sputum Examination Efficiency (SEE) and Case Detection
Efficiency (CDE) (percentage of achievement compared with expectation)
have also been compared according to the category of PHIs. SEE of
XCs & MCs were 70% & 78% respectively as compared to only
26.5% in RCs. The CDE of XCs, MCs & RCs were 69.1%, 36.9% and
14.1% respectively. It is observed that XCs are working satisfactorily
as 35% of the total out patients attend the XCs, their reporting
efficiency being 85%, sputum examination efficiency 70% and sputum
positivity rate 7.8%, indicating good performance, while MCs
had a low sputum positivity rate of 3.8%, suggesting that there
is a large scope for qualitative improvement in Case-finding activity.
While RCs cater to about 20% of the total out patients had
poor performance on all account and need a great deal of technical
supervision.
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KEY WORDS: DTP, PERFORMANCE, PHIs CATEGORY,
CASE-FINDING. |
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