NRHM Workshop on Financial Management A Brief on the Revised National TB Control Programme (RNTCP)

1. NRHM Workshop on Financial ManagementA Brief on the Revised National TB Control Programme (RNTCP) Dr. Somil Nagpal, ICASMBBS, MHA, MBA, F.I.I.I.Central TB DivisionMinistry of Health & Family WelfareNew 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 • Goal • 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 • 1962 National TB Programme (NTP) launched • 1992 NTP review - only 30% diagnosed; of these, only 30% completed treatment • 1997 RNTCP started as a national programme • 1998 Large scale RNTCP expansion began • 2000 135 million population covered; • 2003 741 million population covered; 2nd Joint programme review conducted - rapid expansion and overall quality appreciates • Mar 2006 100% 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) MO-TC, STS, STLS Tuberculosis Unit 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. 3 NRLs 24 IRLs ~12,000 DMCs (one per 50,000-100,000 population) DMC 2 DMC 3 DMC 1 RNTCP Laboratory Network for QA

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. Pre-shipment batch testing Routine quality testing at GMSD Random testing of field drugs and at independent laboratory Drugs and quality assurance system Blister packed drugs are packaged inside patient wise boxes • 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 Quarterly Feedback Additional 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 J A M M U & K A S H M I R H I M A C H A L P R A D E S H U T T A R A N C H A L P U N J A B S I K K I M H A R Y A N A A R U N A C H A L P R A D E S H U T T A R R A J A S T H A N P R A D E S H A S S A M D E L H I B I H A R N A G A L A N D J H A R K H A N D M A N I P U R W E S T G U J A R A T M A D H Y A P R A D E S H B E N G A L M I Z O R A M O R I S S A D & N H A V E L I M A H A R A S H T R A T R M E G H A L A Y A A N D H R A I P U R A P R A D E S H G O A 1.GoI/WB/DFID 2. GFATM Rd 4 3. GFATM Rd 1 4. GFATM Rd 2 5. USAID C H H A T I S G A R H K A R N A T A K A A & N I S L A N D S T A M I L N A D U K E R A L A L A K S H A D W E E P

30. RNTCP Phase II Total project cost – USD 256 million (2006-2011) *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

35. Annualized New Smear-Positive Case Detection Rate and Treatment Success Rate in DOTS Areas, India, 1999-2007* • 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 500 000 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 23000 TB suspects were referred from VCTCs to RNTCP and of them 10638 were diagnosed as having TB and more than 29000 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)

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. Cure rate by district, India Fourth Quarter, 2005 New Smear Positive Case Detection rate, India Fourth Quarter, 2006 <30% 30% – 49.9% 50% - 69.9% >85% >70% 80% – 84.9% <80% Challenge: Addressing wide inter-district variation in programme performance

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….