INDIARevised National TB Control Programme (RNTCP)

Scaling up DOTS though a Mix of Public and Private Health

Providers

Dr. L. S. ChauhanDeputy Director General of Health ServicesCentral TB Division, Directorate of Health

Ministry of Health and Family WelfareGovernment of India

Total districts: 87

RNTCP implementation Quarter 1 2000

Total population: 188 million

2000 population estimated from 2001 census

Total districts: 187

Total population: 389 million

RNTCP implementation Quarter 1 2001

Population as per 2001 census

Total districts: 245

Total population: 470 million

Projected population of 2002 based on 2001 census

RNTCP implementation Quarter 1 2002

Total districts: 364

Total population: 665 million

Projected population of 2003 based on 2001 census

RNTCP implementation Quarter 1 2003

India: DOTS ImplementationStatus by District, 30th Sept 2004

Type of districts / reporting units

No. of districts / reporting

units

Population (in million) *

Implementing 521 906

35

8

141

Appraisal done 18

Ready for appraisal 5

Preparing 87

* 2004 projected population based on 2001 census.ImplementingAppraisal doneReady for appraisalPreparing

DOTS Expansion, India (1993-2005)

0

200

400

600

800

1000

1200

IV/93 II/94

IV/94 II/95

IV/95 II/96

IV/96 II/97

IV/97 II/98

IV/98 II/99

IV/99 II/00

IV/00 II/01

IV/01 II/02

IV/02 II/03

IV/03 II/04

IV/04 II/05

IV/05

Quarter/Year

Popu

latio

n in

mill

ion

.

Country population Actual DOTS coverage Planned DOTS coverage

Note: Actual and Planned DOTS coverage coincide

Population in India covered under DOTS and total tuberculosis patients put on treatment each quarter

2 3 7 6 1 5

0

100

200

300

400

500

600

700

800

900

1000

I/94

III/94 I/95

III/95 I/96

III/96 I/97

III/97 I/98

III/98 I/99

III/99 I/00

III/00 I/01

III/01 I/02

III/02 I/03

III/03 I/04

Quarter/Year

Popu

latio

n co

vere

d (m

illio

ns)

0

50000

100000

150000

200000

250000

300000

Tota

l pat

ient

s tre

ated

Total patients treatedPopulation coverage(in millions)

314,935

>100,000 patients put on

treatment every month>1 million patients put

on treatment in last 4 quarters

Important Milestones in PPM DOTS1993 RNTCP started as pilots1995 PPM model started in Hyderabad1998 RNTCP scaling up initiated

2000-2003 PPM models in Delhi, Kannur, Kollam, Mumbai, Tea-gardens of north-east started

2002 Private Practitioners (PP) Schemes published2003 PPM DOTS activities initiated in many districts

Early 2000 135 million population covered by RNTCP

2001 Schemes for involvement of NGOs publishedEnd 2001 450 million population covered

2003 Intensified PPM scaling up begins in 14 urban sitesSept 2004 906 million population covered by RNTCP

>160 Medical colleges, >800 NGOs, >5000 PPs, >80 corporate houses involved

Health Care Providers in IndiaMinistry of health Other Ministries Non-Government

Directorate of health (RNTCP, primary health care)Directorate of Medical education (Medical Colleges)

RailwaysEmployees State InsuranceMiningCoalSteelPortsPrisonsArmed forces

NGOsPrivate hospitalsCorporate industries Private practitionersTraditional practitioners

Kannur Model: Increase in Case Detection by Involvement of Private Hospitals (Kannur, Kerala, India; 2000- 2002)

0102030405060708090

100

q1 q2 q3 q4 q1 q2 q3 q4 q1 q2 q3 q4

Rat

e pe

r 100

,000

pop Tot

Public&Pvt.

Tot Public

New Sm+Public&Pvt.

New Sm+Public

KPPM

2000 2001 2002

Tea Estate Model: Case Detection by Corporate Sector in Dibrugarh and Jalpaiguri Districts in North-eastern India,

2001–2002

District Sector New S+ve % All cases

Dibrugarh Tea Estate 638 42 1472

1883

3679

5825

44

Rest 865 58 56

Jalpaiguri

%

1923

2508

Tea Estate 43 39

Rest 57 61

NGO Model: Contribution of Falah-e-Am NGO toCase Detection in Meerut, India; 2001–June 2003

New S+veN=7206

%

1270 18

825936

All CasesN=15504

%

Falah-e-Am 2638 17

Rest of Meerut 12866 83

Inter-sectoral Coordination

Medical Colleges (under directorates of medical education in respective States) involved through National, Zonal and State Task ForcesHealth care facilities under ministries other than health have started implementing DOTS, including:

RailwaysEmployees State Insurance (ESI)Mining, Coal, Shipping

Anganwadi workers (Ministry of Human Resources Development) involved as “DOT-Providers”

Intensified PPM sitesPPM sites started in 2003

Pilot Site State

Ahmedabad Gujarat

Bangalore Karnataka

Bhopal Madhya Pradesh

Chandigarh Chandigarh

Chennai Tamil Nadu

Delhi Delhi

Kolkata West Bengal

Lucknow Uttar Pradesh

Patna Bihar

Pune Maharashtra

Ranchi Jharkhand

Thiruvanthapuram Kerela

* Additional sites

Process of PPMOrientation of Programme staffListing of health care providersPrioritization of providers by patient loadOrientation of providersTraining of providersTraining of Programme staff on specially designed surveillance systemRecruitment and training of additional PPM field staffInvolvement of health providers under Programmeguidelines and schemes, using existing Programmefunds

New S+ve Cases Detected by Provider Type 2nd and 3rd qtr 2004

Health (H) = 6430 (61.3%)Government (G) = 429 (4.1%)Medical College (M) = 1929 (18.4%)Corporate Sector (C) = 24 (0.2%)Private Practitioners (P) = 824 (7.9%)NGOs (N) = 849 (8.1%)

Total = 10485

Contribution by Provider type in New S+veCase Detection (Q2 & Q3, 2004)

0%

20%

40%

60%

80%

100%

Ahmed

abad

Banga

lore

Bhopa

lChan

digarh

DelhiKolk

ata

Patna

Ranchi

Chenna

iLu

ckno

w

Pune

NPCMGH

New Sm+ve

All Cases

0

2000

4000

6000

8000

10000

12000

14000

16000

18000

2002

Q120

02Q2

2002

Q320

02Q4

2003

Q120

03Q2

2003

Q320

03Q4

2004

Q120

04Q2

2004

Q3

Intensified PPM

Trends in Case Detection in PPM SitesN

umbe

r of c

ases

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

1999

Q119

99Q2

1999

Q319

99Q4

2000

Q120

00Q2

2000

Q320

00Q4

2001

Q120

01Q2

2001

Q320

01Q4

2002

Q120

02Q2

2002

Q320

02Q4

2003

Q120

03Q2

2003

Q320

03Q4

2004

Q120

04Q2

Annualised New S+ve CDR Success rate

Annualized new smear-positive case detection rate and treatment success rate in DOTS areas, 1999-2004 *

•Population projected from 2001 census•Estimated no. of NSP cases - 75/100,000 population per year (based on recent ARTI report)•2nd quarter 2004 data is provisional

0%

10%

20%

30%

40%

50%

60%

70%

80%

1999 2000 2001 2002 2003 2004 2005 2006 2007Year

% C

ases

det

ecte

d of

tota

l est

imat

ed fo

r Ind

ia .

Target 70%

India: Rapid Progress Towards 70% Case Detection*

•Estimated no. of NSP cases - 75/100,000 population per year (based on recent ARTI report)

Conclusions

Unprecedented rapid scale up of DOTS DOTS services being delivered through a mix of public and private health care providersCase detection and treatment success on course to meet global targets of 2005Priority at national level is consolidation, effective involvement of major health care providers and quality of services

Thanks