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.