1. NRHM Workshop on Financial Management A Brief on the Revised National TB Control Programme (RNTCP)
Dr. Somil Nagpal, ICAS MBBS, MHA, MBA, F.I.I.I. Central TB Division Ministry of Health & Family Welfare New Delhi

2. Magnitude of the TB Problem in India

3. India is the highest TB burden country globally accounting for one fifth of the global incidence
Global annual incidence = 8.9 million
Source: WHO Geneva; WHO Report 2006: Global Tuberculosis Control; Surveillance, Planning and Financing

4. TB Burden in India
Incidence of TB disease: 1.8 million new TB cases annually (0.8 million new infectious cases)
Prevalence of TB disease: 3.8 million bacteriologically positive (2000)
Deaths: about 370,000 deaths due to TB each year
TB/HIV: >5 million people with HIV; >2 million co-infected with HIV & TB
About 5% of TB patients estimated to be HIV positive
MDR-TB in new TB cases ≤3% and ~12% in Re-treatment cases
Substantial socio- economic impact

5. Addressing the Problem: Goals and Objectives

6. RNTCP – Goal and Objectives
The goal of TB control Programme is to decrease mortality and morbidity due to TB and cut transmission of infection until TB ceases to be a major public health problem in India.
Objectives:
To achieve and maintain a case detection of at least 70% of new sputum positive TB patients
To achieve and maintain a cure rate of at least 85% in such patients

7. UN Millennium Development Goals
Goal 6: Combat HIV/AIDS, malaria and other diseases
Target 8: By 2015, halted and begun to reverse the incidence of malaria and other major diseases
Indicator 23: between 1990 and 2015 to halve prevalence of TB disease and deaths due to TB
Indicator 24: to detect 70% of new infectious cases and to successfully treat 85% of detected sputum positive patients

8. In addition to implementing core DOTS activities, India is implementing most of the additional components of the Stop TB Strategy

9. Structure of the TB Control Efforts in India

10. TB control efforts in India
National TB Programme (NTP) launched
NTP review - only 30% diagnosed; of these, only 30% completed treatment
1997 RNTCP started as a national programme
Large scale RNTCP expansion began
million population covered;
million population covered; 2nd Joint programme review conducted - rapid expansion and overall quality appreciates
Mar % population covered;
Next 5-year plan approved with additional activities

11. Structure of RNTCP at State level
STO, Deputy STO
MO, IRL Microbiologist,
Accountant, IEC Officer, SA,
DEO, TB HIV Coordinator
State TB Cell
DTO, MO-DTC, LT, DEO,
Urban TB Coordinator, Driver
Nodal point for TB control
District TB Centre
One/ 500,000
(250,000 in hilly/
difficult/ tribal area)
Tuberculosis Unit
MO-TC, STS, STLS
One/ 100,000
(50,000 in hilly/ difficult/
tribal area)
MO, LT
Microscopy Centre
TBHVs, DOT Provider –
MPW, NGO, PP,
Community Volunteers
DOT Centre

12. RNTCP provides free and quality assured diagnosis by sputum microscopy

13. RNTCP Case finding / diagnostic services
Sputum microscopy is the primary tool for diagnosing and monitoring
The role of X-Ray’s in the diagnosis of Pulmonary TB is minimal.
Diagnostic algorithms for diagnosis of
Pulmonary TB (Adult & Pediatric)
Extra Pulmonary TB (TB Lymphadenitis)
Referral linkages for secondary and tertiary hospitals for diagnosing EP TB

14. RNTCP Laboratory Network for QA
3 NRLs
24 IRLs
~12,000 DMCs
(one per 50, ,000
population)
DMC 1
DMC 2
DMC 3

15. Quality Assurance Protocol (QA)
External Quality Assessment (EQA)
Internal Quality Assurance (Quality Control)
Quality Improvement (QI)
On Site Evaluation (OSE)
Panel Testing
Random Blinded Rechecking (RBRC)
Instrument checks
Reagent quality check
Data Collection
Data Analysis
Solving problems

16. Innovations in Treatment and Logistics in RNTCP

17. Patient-wise drug boxes
A unique feature of RNTCP are the patient-wise drug boxes (for adult and paediatric cases), which improve patient care, adherence, and drug supply and drug stock management

18. Blister Packed Drugs Packaged for Intensive Phase & Continuation Phase Inside a Patient Drug Box (Cat-I)

19. Drugs and quality assurance system
Blister packed drugs are packaged
inside patient wise boxes
Pre-shipment batch testing
Routine quality testing at GMSD
Random testing of field drugs and at independent laboratory
Intensive phase 2-3 months
Continuation phase 4-5 months

20. All patients receive free drugs under direct observation by a DOT provider (health worker or community based volunteer)
accessible and acceptable to the patient and accountable to the health system

21. Supervision & Monitoring Strategy

22. Proper documentation using standard Records and Registers

23. Programme Surveillance System
Peripheral Health
Institute (DMC and other PHIs)
Monthly PHI Report
Tuberculosis Unit
System electronic from district level upwards
Quarterly CF, SC, RT, PM Reports
Additional
Feedback
Quarterly
Feedback
District TB Centre
Electronic reports)
Quarterly Reports
CF, SC, RT, PM
State TB Cell
Central TB Division

24. EPI-CENTRE: RNTCP Data processing system

25. RNTCP “Supervision and Monitoring strategy”
Strategy document developed and published in March 2005
All states and districts implementing the strategy
All state/district programme staff trained in the strategy

26. Other Activities under RNTCP
Emphasis on maintaining and consolidating the quality of existing diagnostic and treatment services
Also emphasizing on the following activities :
Inter-sectoral collaboration including Medical Colleges
Supervision and Monitoring
Expanding services to difficult areas
IEC activities
TB-HIV co-ordination
Drug Resistance Surveillance
Operational research
Newer Activities:
IRL strengthening for sputum microscopy EQA implementation and provision of culture and drug sensitivity testing
Introduction of pediatric patient wise drug boxes
DOTS Plus implementation in phased manner

27. Financial Management in RNTCP

28. Decentralized Financial Management
Central TB Division
Funds released in two installments
on receipt of Statements of Expenditure (SOE)
Plan of budget
State Health/ TB Control Societies
Funds released quarterly on receipt of SOE giving activity-wise details
Plan
District Health/ TB Control Societies

29. Current Financial Support to RNTCP
1.GoI/WB/DFID
2. GFATM Rd 4
3. GFATM Rd 1
4. GFATM Rd 2
5. USAID R A J S T H N O I G U M D Y P E B K
& L W V C Z

30. RNTCP Phase II RNTCP with financial Assistance from other sources
Total project cost – USD 256 million ( )
Funding Source
No. of districts/ Population
Amount
Period
World Bank-RNTCP Phase II
~1080 million
US $ 170 million
Oct 2006–Sept 2011
DFID (Drugs) under Phase-II
500 million
US $ 62.5 million
Oct 2005-Sept 2010
RNTCP with financial Assistance from other sources
GFATM
(Round 4)
120 million
(Entire AP/Orissa)
US $ million
(Round 2)
110 million
(Bihar – 30 Dist; UP – 27 Dist)
US $ million
2004 – 2009
(Round 6)**
61 million
Entire Chhattisgarh/ Jharkhand/Uttarakhand
US $ million
2007 – 2012
USAID
23 million
(Entire Haryana)
US $ 6.58 million
2003 to Mar 2008
*All GFATM rounds have an NGO sub-project
** GFATM Rd 6 approved to support implementation in Rd 1 states ; under process of approval

31. Financial Management in RNTCP
System of fund releases based on Action Plans (District and State level) since inception
Releases linked to submission of FMRs- timely submission of FMR (SoE, UC, AR) is critical. Thus, there are no UCs overdue.
Comprehensive Finance and Procurement Manuals
Training in Financial Management for all levels of staff, including Programme Officers
Electronic SoE submission is 100%- districts and states

32. Summary of Achievements of RNTCP

33. DOTS Coverage by District, India
31st March 2006
Total districts: 632
Total population: 1114 million
Nation wide DOTS coverage
632 districts – 1114 million
people covered under RNTCP

34. Population covered under DOTS and total TB patients put on treatment in each quarter
341877
>100,000
patients put on
treatment every month
1.4 million patients put
on treatment in 2006
Yearly total population projected from 2001 census.

35. Annualized New Smear-Positive Case Detection Rate
and Treatment Success Rate in DOTS Areas, India, *
Treatment success has recently exceeded the global target of 85%
Case Detection in DOTS areas has recently attained global target of 70%
Population projected from 2001 census
Estimated no. of NSP cases - 75/100,000 population per year (based on recent ARTI report)

36. Achievements Fastest DOTS expansion in the world
Full strategy coverage of all 632 districts with a population of over 1.1 billion
Over 2400 TB Units and ~12500 Microscopy Centres upgraded;
Network of over 4 lakh DOT centres – within the public health system and through involvement of PPs, NGOs and community volunteers
Over 25 million TB suspects examined
Over 6.8 million TB patients treated
High case detection and success rates
Over 1.2 million deaths prevented

37. Achievements
Over staff trained using standardized training modules
System of quality assurance of sputum microscopy in place
Quality drugs at no cost to the patients
Programme organization at all levels – emphasis on supportive supervision and monitoring
Excellent recording and reporting system – electronic reporting from district upwards
Web based IEC resource centre developed

38. Achievements
Over 2200 NGOs, 14,500 PPs, 140 Corporate houses and 234 Medical colleges involved
Collaboration of IMA, IAP, NGOs and PPs
Service delivery through community volunteers has improved access
Joint action plan with NACP
In the year 2005, more than TB suspects were referred from VCTCs to RNTCP and of them were diagnosed as having TB and more than TB patients were tested for HIV and of them 6338 were HIV positive.
Plan to address MDR-TB
In a study area, the strategy reduced TB prevalence and transmission

39. Outlays and expenditure (2002-03 to 2006-07)
Year wise details
Allocation
(Rs. in Crores)
Expenditure
115.00
96.95
117.90
125.00
133.63
186.00
187.70
202.17
220.97

40. Emerging evidence of impact
Estimated deaths declining - Deaths due to TB reduced from 500,000 to <370,000 a year
Evidence from TRC, Chennai studies show declining trends in infection and disease prevalence rates
Ongoing in-depth analysis of routine notification data for evidence of impact

41. Challenges Consolidate and maintain quality of DOTS services
Improve case detection rates and maintain treatment success rates
Meet global case finding targets and achieve TB related MDGs
Addressing HRD challenges
State and district -level supervision, managerial capacity and monitoring are weak
Staff shortages and frequent transfers weaken the quality of service delivery
Public Private Mix
Private sector involvement is insufficient – need for further strengthening
Need for improved coordination with the Public sector health units (outside Health sector)
Addressing MDR TB
Second line drugs are widely prescribed
Establishing and accreditation of IRLs and start DOTS Plus
Further strengthening of TB HIV collaborative activities

42. New Smear Positive Case Cure rate by district, India
Challenge: Addressing wide inter-district variation in programme performance
New Smear Positive Case
Detection rate, India
Fourth Quarter, 2006
<30%
30% – 49.9%
50% %
>70%
Cure rate by district, India
Fourth Quarter, 2005
>85%
80% – 84.9%
<80%

43. Role of Programme Management Support Units and State level in implementing RNTCP
Facilitate regular meetings of District Health Society, including that of TB Program Committee
Ensure key staff appointment - LT ,STLS ,STS and other essential staff
Acceleration of staff recruitment process/posting of staff
Facilitating release of funds/vehicle procurement/up gradation of laboratory
Quarterly review/monitoring of TB programme / supervisory visits
Ensuring community participation
Advocating RNTCP in various forum
No diversion of vehicles and other resources allotted for TB supervisory activities
AWW involvement as DOT providers
Involvement of NGOs and Private Practitioners
Ensure timely payment (remuneration etc) to contractual staff
Ensure timely submission of SoE, UC, AR etc.

44. Thank You….