New Vision for Revised National Tuberculosis Control Programme (RNTCP): Universal access - “Reaching the un-reached”

RNTCP Phase II (2006-2012): Achievements (till December 2011) and challenges

Since its inception, the Programme has initiated over 13.8 million patients on treatment, thus saving more than 2.5 million additional lives in comparison to earlier programme4. The Programme has consistently maintained the treatment success rate >85 per cent since inception and NSP case detection of 70 per cent since 2007 after whole country coverage. In 2011, the NSP case detection rate was 71 per cent and treatment success rate 87 per cent. Quality assured sputum smear examination facilities are available through more than 13,000 Designated Microscopy Centers (DMCs) across the country. A network of more than 4 lakh (0.4 million) DOT providers are available to provide quality assured DOT services. All States are implementing the ‘Supervision and monitoring strategy’5 – detailing guidelines, tools and indicators for monitoring the performance from the peripheral health institutions level to the national level.

To improve access to tribal and other marginalized groups the Programme has developed a Tribal Action Plan6 which is being implemented with the provision of additional TB Units and DMCs in tribal/difficult areas, additional staff, compensation for transportation of patient and attendant, and higher rate of salary to contractual staff. Innovative public-private mix (PPM) schemes have been formulated by the Programme to encourage non governmental organizations (NGOs) and private practitioners to encourage their participation and contribution to TB control efforts in the country7. More than 3000 NGOs, 30,000 private practitioners and 150 corporate health facilities are involved in the provision of RNTCP services. Presently, 291 medical colleges (including private colleges) have been involved in RNTCP. Health facilities in government sectors outside Health Ministry have been involved viz. Employees State Insurance, Railways, Ports and the ministries of Mines, Steel, coal, etc., Intensified PPM activities are being undertaken with Indian Medical Association (IMA) in 16 States and with Catholic Bishop Conference of India (CBCI), a faith based organization (FBO), in 19 States2. Under Global Fund Round 9, civil society principal recipient (PR) International Union against TB and World Vision would be leading an undertaking of focused Advocacy, Communication and Social Mobilization (ACSM) activities in 374 districts of the country2.

It is estimated that 4.85 per cent of the TB patients are human immunodeficiency virus (HIV) infection positive8. NACP (National AIDS Control Programme) and RNTCP have jointly developed “National framework of joint TB/HIV collaborative activities”9 and these are being implemented in the country. In 2011, around 6,91,658 TB suspects were referred from Integrated Counselling and Testing Centers (ICTC) to RNTCP and of them, about 83,887 were diagnosed as having TB and initiated on DOTS. In the same period about 6,00,000 TB patients (67% of registered TB patients in State implementing intensified TB-HIV package) were tested for HIV, and of them about 44,000 were diagnosed as HIV positive and offered access to HIV care including co-trimoxazole preventive therapy (CPT) and anti retroviral therapy (ART).

The drug resistance surveys estimate the prevalence of multidrug resistant TB (MDR-TB) to be about 3 per cent in new cases and 12-17 per cent in re-treatment cases and also indicate that the prevalence of MDR-TB is not increasing in the country10. Regardless, India is one of highest MDR-TB burden countries in the world with an estimated 99,000 incident MDR-TB cases11. The Programme is in the process of accelerating the establishment of a network of about 43 accredited Culture and Drug Susceptibility testing (DST) Laboratories by the end of 2013 across the country in a phased manner for diagnosis and follow up of MDR- TB patients, with the support of the Foundation for Innovative New Diagnostics (FIND-India) and other partners2. Presently there are 37 accredited culture and DST laboratories under RNTCP. These include four National Reference Laboratories, 15 State level culture and DST Laboratories, and 18 laboratories in other sectors. The Programmatic Management of drug-resistant TB services were initiated in the States of Gujarat and Maharashtra in 2007 and by the end of 2011 it was expanded to all States, over 6,994 MDR-TB patients have been initiated on treatment2.

As a result of the implementation of RNTCP in the country, prevalence of all forms of TB has been brought down from 338 per 100,000 population (1990) to 249 per 100,000 population in 2009 and TB mortality in the country has reduced from over 42 per 100,000 population in 1990 to 23 per 100,000 population in 2009 as per the WHO global TB report 20101. These India estimates by WHO are based on mathematical modeling, get altered every year and debatable. Repeat population surveys conducted by Tuberculosis Research Centre (TRC, now National Institute of Tuberculosis Research, NITR), Chennai in Chengleput, Tamil Nadu, indicated that since RNTCP implementation a 12 per cent annual decline in prevalence has occurred, much greater than the decline observed in the preceding decades in the same area12. The Programme has initiated surveys to assess the impact of RNTCP and progress towards TB related millennium developmental goals. These include: Disease prevalence surveys at seven sentinel sites and the National annual risk of TB infection survey. The results of these surveys will be used to realistically estimate the disease burden in the country in consultation with both national and international technical experts.

Despite this progress, TB incidence and mortality are still very high, and in 2009 an estimated 280,000 people died of TB in the country1. A vast proportion of TB cases continue to be initially managed in the private sector, frequently inadequately and without subsidy for diagnosis and treatment that patients can frequently ill-afford. Nearly 50 per cent of the retreatment cases notified under RNTCP are treated in other sectors before reaching RNTCP, suggesting inadequate treatment and possible amplification of drug resistance (unpublished data from Central TB Division, GoI). The most serious challenge to TB control is in urban areas. Urban areas still experience intense levels of TB transmission, where urban primary health care systems tend to be weaker and private health care predominates. MDR-TB/XDR-TB occurs due to misuse of anti-TB drugs and interrupted treatment, largely in the private sector, and then can be spread in the community unless it is correctly diagnosed and treated. Linking HIV-infected TB patients to HIV care and support and implementing measures to prevent TB in HIV care settings need further strengthening. Public private mix efforts though beneficial, remain a very small proportion relative to the large numbers of private sector providers; hence the impact of these efforts has so far been relatively limited13.

Vision and targets for RNTCP during the 12^th Five Year Plan (2012-2017)

The vision of the Government of India is for a “TB-free India” with reduction in the burden of the disease until it is no longer a major public health problem.

To achieve this vision, the Programme has now adopted the new objective of aiming to achieve ‘Universal access’ for quality diagnosis and treatment for all TB patients in the community14. This entails sustaining the achievements of the Programme to date, and extending the reach and quality of services to all persons diagnosed with TB. In particular, by end-2017, the Programme aims to achieve the following targets: (i) Early detection and treatment of at least 90 per cent of estimated TB cases in the community, including HIV-associated TB; (ii) Initial screening of all re-treatment smear-positive TB patients for drug-resistant TB and provision of treatment services for MDR-TB patients; (iii) Offer of HIV counselling and testing for all TB patients and linking HIV-infected TB patients to HIV care and support; (iv) Successful treatment of at least 90 per cent of all new TB patients, and at least 85 per cent of all previously-treated TB patients; and (v) Extend RNTCP services to patients diagnosed and treated in the private sector.

Programme activities necessary to achieve RNTCP (2012-2017) targets

In particular, by end-2017 the programme aims to achieve following targets: