The rapid expansion of RNTCP implementation in this vast and diverse county with quality

maintenance demands proactive involvement of policy makers, programme managers, researchers

and health functionaries.



Mid-term goal for the programme have to be defined. Problems in achieving these objectives have to

be identified and a research agenda needs to be formulated to answer the constrains identified. Research,

by being linked to the constrains and objectives, will always be relevant to TB control programme and

the findings would influence policy and practice. Operational research should become an integral

component of the programme management

Narayanan, P R

Paul Kumaran, P

Santha, T

NIRT Institutional Repository

Theme: TB MANAGEMENT IN INDIAOFFICIAL PUBLICATIONOFTHE INDIAN SOCIETYOF HEALTHADMINISTRATORSHealth Administrator Vol : XV, Numbers : 1-2, pg. 113-117TUBERCULOSIS CONTROL STRATEGIES:CHALLENGES TO HEALTH MANAGEMENT RESEARCHNARAYANAN P R*, SANTHA T**, PAUL KUMARAN P**The rapid expansion of RNTCP implementation in this vast and diverse county with qualitymaintenance demands proactive involvement of policy makers, programme managers, researchersand health functionaries.* * *Mid-term goal for the programme have to be defined. Problems in achieving these objectives have tobe identified and a research agenda needs to be formulated to answer the constrains identified. Research,by being linked to the constrains and objectives, will always be relevant to TB control programme andthe findings would influence policy and practice. Operational research should become an integralcomponent of the programme management.I. INTRODUCTIONControl of tuberculosis (TB) has been evadinghumankind despite more than a century afteridentification of the causative organism, and more thanhalf a century of effective anti-tuberculosis treatmentbeing available. The failure in controlling tuberculosisis attributed to poor management of TB controlprogrammes. To top it all, confounding HIV scenariohas worsened the situation of TB disease forcing theWorld Health Organization to declare TB as a globalemergency in 1993. TB control programmes to beeffective, they are recommended to be integrated withthe general health care delivery system (1). In recentyears DOTS (directly observed treatment, short-course has emerged as the most cost effective strategy everadopted (2) and is developed based on scientific evidenceand recommends the use of a uniform protocolthroughout the world. The strategy comprises fivecomponents, namely, political and administrativecommitment, quality diagnosis based on sputummicrosoopy, use of quality drugs, directly observedtreatment, and maintenance of a recording and reportingsystem.The national tuberculosis control programme(NTP), formulated and launched in 1962 in India, alsointegrated tuberculosis control activities with the generalhealth services (3). However, a programme review, donein 1992, after three decades of implementation of NTP,showed that it had not created a significantepidemiological impact mainly due to managerialweakness, and inadequate funding; over-reliance on x-ray for diagnosis, use of non-standard treatmentregimens, low rates of treatment completion, and lackof systematic information on treatment outcomes wereother drawbacks of the NTP (4). India therefore adoptedthe DOTS strategy in 1998 under the Revised NationalTuberculosis Control Programme (RNTCP), after pilottesting in 1993 (5), It is now being implemented in aphased manner. Today RNTCP has become the secondlargest and the fastest-growing DOTS programme inthe world (5), covering more than 450 million of India’sone billion population (6). The rest of the population iscovered by the national tuberculosis programme (NTP)which is being phased out gradually. The RNTCP isexpected to cover 80% of the country by 2004 and theentire population by 2005 (7).The challenges with the RNTCP are manifold,related to the structure and technology as well asprogramme implementation and personnel, material andfinancial management.II. STRUCTURAL CHALLENGESThe delivery of health care services in India isthrough the organized government health services,public sector undertakings, and by a large private sectorthat includes individual private providers, corporatesector, and non-governmental organizations.The organogram of the government health sectorfor tuberculosis control, presented in figure 1, shows thatthe technical hierarchy is well defined (8); but theadministrative hierarchy of the programme is complex.Health being a stats subject, each state in India has itsown priority agenda and methodology of implementation.To cite a few examples, some states have a singledirectorate for health services responsible for all issuesof health; some have separate directorates for medicaleducation and health services, and still others have morerefined, specific and separate directorates for medicaleducation, medical services and public health services.Thus the administrative power equations and hierarchydiffer between states.* Director, ** Dy Director, Tuberculosis Research Centre (ICMR), Chennai, India,e-mail: trcicmr@md3.vsnl.net.in; prnarayanan@vsnl.com1 1 3This dual structure of the health system in India,i.e., separate administrative and technical control,creates lack of uniformity in the implementationstrategies between states and makes it difficult for theprogramme planners and implementers.III. TECHNOLOGICAL CHALLENGESIn the RNTCP, the sub-district level (tuberculosisunit-TU) is the functional unit for the management andimplementation of the control programm e. The TUs sendthe programme (technical and logistics) report on aquarterly basis to the district. The district in turnconsolidates the reports and sends it to the central levelwith a copy marked to the state level programme officers.As the financial accountability of the stats is minimal,the ownership of the programme is relatively low at thislevel, This has resulted in lack of adequate involvementof the state in programme monitoring and supervision.Managerial research is needed for identification ofeffective methods of monitoring, which are, simple,effective and quick to use, but at the same time satisfyingevery level ofhierarchy for implementation.For the effective implementation of any controlprogramme, a situation analysis and estimation of theburden of the disease is essential to ascertain thematerials and finances required. There is nocountrywide estimate available at present, for theburden of tuberculosis infection or disease in India.Currently, the burden of disease is calculated on anaverage annual risk of tuberculosis infection (ARTI) of1.7% (9) for the entire country, (This estimate was basedon a few regional observations). No countrywideestimate is available for ARTI. The materials andfinancial requirements for the programme are alsocalculated based on the caseload estimation of 50 newbacillary positive pulmonary tuberculosis patients perlakh per year for an ARTI of 1% (10).One diagnostic facility (microscopy center-MC,where sputum examination is done) is made availablefor every one lakh population. Each MC caters to about3 primary health care centers (PHC). This is the onlycomponent of DOTS that is centralized as different fromthe earlier NTP. This is to maintain the quality ofdiagnosis. The drawback here is that a large number ofpatients need to travel long distances for sputumexamination resulting in dropouts. Managerial efficiencyis required to minimize dropout rates in the programme.Human immuno-deficiency virus (HIV) infectionis changing the scenario of tuberculosis in India (11). Itis fueling the tuberculosis epidemic, since HIV promotesprogression to active disease in people with tuberculosisinfections with an estimated 7% developing TB annually(12), either acquired recently or in the past. The breakdown rate of tuberculosis in individuals with HIV/TBco-infection needs consideration for determining thecaseload and procurement of logistics.Though the government health system is complex,it is well organized. However, there is evidence that morethan 50% of the tuberculosis patients approach privateproviders (PP) first for relief (7). The private health sectorin India is one of the largest in the world, comprising80% qualified doctors, 75% dispensaries and 60%hospitals (7). The PP has become the de facto primaryhealth care provider in India. The relative advantagesof PP include easy access, convenient timings, bettercommunication and greater confidentiality, as observedin a study conducted by the Tuberculosis ResearchCentre (under publication). In addition, is the patient’sperception that the private sector offers better quality ofcare. There is thus no escaping the fact that the healthsystem of the country has to evolve appropriate methodsin order to involve this large sector in the tuberculosisprogramme delivery. Their participation in theprogramme is necessary for achieving the “global target"of 70% case detection and 85% cure for tuberculosiscontrol. Also, the various public sector undertakings (e.g.,railways, employees state insurance hospitals, centralgovernment health services, etc), responsible for thehealth of their employees and families, should be involvedeffectively in the RNTCP and made committed andresponsible to the programme.In the context of drug procurement, that is basedon the disease burden as well as the impact of DOTSimplementation in the following years, research shouldbe initiated to assess the actual disease burden. As adisease survey providing the actual disease burden isnot cost effective, there is a need to develop better toolsto monitor.IV. CHALLENGES IN PROGRAMMEIMPLEMENTATIONIndia has evolved a national level programmeguideline for RNTCP. With its geographic and culturaldiversity, the policy needs constant evaluation andchanges, if required.The administrative unit of the TB controlprogramme is the district, with the district tuberculosisofficer (DTO) as programme manager. The DTO isresponsible for preparing the district for implementationand to ensure effective functioning of the programme inhis area. To achieve this there is a need to plan strategiesfor programme implementation. A blue print of the workschedule needs to be prepared and implemented in arealistic way. Decision of who will do what, otherwisetermed ‘organizing’, needs to be done. For an effectiveprogramme, training of health workers, development ofInformation Education and Communication (IEC) andadvocacy materials, uninterrupted drug supply andcoordination with Non Government Organisations(NGOs), PPs and, the health care service needs to be inplace. Grouping of related activities, and networking ofpositions for effective communication channels needs114 planning and organizing. Delegation of decision-making115authority to subordinates, where needed, is the powerof the manager.V. PERSONNEL MANAGEMENTRecruitment of suitable subordinates andtheir motivation is a major requisite forsuccessful continuation of the programme.Influencing the behaviour of these subordinates bybalancing the level of authority andrelationship would result in successful programmeimplementation. A good leader needs to be dynamic,i.e. capable of changing leadership style depending onthe situation. This calls for managerial capacitybuilding for programme managers at all levels. Themode of training, modules for training, andimplementation of the skills acquired for improvingthe programme performance need managementresearch.One of the main reasons for not obtaining thedesired results with NTP in India was lack ofsupervision (7). There was only one supervisory teamfor the entire &strict and the supervisory officer wasthe DTO. Under the RNTCP, anadditional supervisory unit has been created for every500,000 population, with a senior treatmentsupervisor (STS) and a senior tuberculosis laboratorysupervisor (STLS) performing supervision on a dailybasis, and a medical officer in charge of TB controlactivities (MO-TC) performing periodic supervision.Delegation of supervisory powers does not meangiving away responsibility. In fact, this helps todecentralize supervisory powers, thereby making itmore effective.In the current programme, supervision of thesupervisory staff is not in place. So, there is a need toevaluate the existing system in terms of its efficacy.Also, at present the 83% and STLS in most places areon contractual appointment. The programme shouldattract the right kind of people with the capacity tolearn and be committed to the programme. The abilityof the health system to give emotional acceptance tothese staff in the form of job security is also a concern.Since the TB control programme is integratedinto the primary health care, there is a need to buildcapacity at the peripheral level for all categories ofstaff. The training materials have been designed tobring uniformity in the technical aspects of casemanagement and programme management. Trainingof the key personnel is done at the central resourceinstitutes, who in turn train the other staff.Selection of key staff for training is a crucialissue, since they are responsible for training ofworkers at the grassroots level. Moreover, there is nosystem to ensure uniformity of training. Though animmediate assessment of the training is done usingpre and post-test scores, there is no method to assessthe long-term impact of training. A system for long-term assessment needs to be evolved. Frequenttransfer of the trained personnel is another bottleneckof the RNTCP. Training should also include capacitybuilding to manage, and to undertake operationalresearch that will help in improving the performance.Methodologies for in-service training have to bedeveloped. Adherence of the health care staff to theguidelines of RNTCP needs to be monitored.VI.    MATERIALS MANAGEMENTPresently, the drugs are purchased through aglobal tender that is approved by the department ofhealth and the World Bank. They are beingdistributed to the districts directly and a stock issupplied to the Government Medical Stores Depot.The districts in turn supply the required drugs to thesub district level, from where it is distributed to thehealth facilities. A more effective procurement anddistribution system for drugs, that is timely and cost-effective, needs to be evolved. Other consumables arealso procured and distributed from thedistrict to the lower levels.Maintenance of stocks at various levels needsto be optimal without interference with the supply. Asthe shelf life of the drugs is too short, ensuring properinventory control is a challenge. Ways to minimizewastage and pilferages are also required, as anti-tuberculosis drugs are costly and misuse can lead toemergence of drug resistance.VII. FlNANCIAL MANAGEMENTThe financial resources for the RNTCP aredistributed directly to the districts through thedistrict tuberculosis control societies (DTCS).Avoiding cumbersome administrative and financialprocedures, the DTCS is expected toensure smooth flow of funds for utilization at thecommunity level. Moreover, as the states are to havestate tuberculosis control societies, the interplay ofpower equations between both thesesocieties (state and district) need to be monitored andevaluated for optimal use of the scarcefinancial resources. The DTCS implements theprogramme functionally, administratively andannually. Also, it improves coordination between thegovernment and non-governmentfunctionaries at the grassroots level...Adequate capacity building is needed for allthe district level programme officers for managingfinance in an optimal way. Anongoing continuous mechanism is required to evaluatethe utilization of funds at he district level. Farther thedecentralization, more difficult it is to monitor andsupervise, and keep the providers accountable to thesystem. So, there is a need to evaluate116the efficacy of financial decentralization in the currentcontext and take appropriate steps to improve thequality of financial management.VIII.  CONCLUSIONThe rapid expansion of RNTCP implementationin this vast and diverse country with qualitymaintenance demands proactive involvement of policymakers, programme managers, researchers andhealth functionaries. Though the current reportingand recording system of RNTCP assists in regional-and state-wise evaluation of the programmepeformances. India needs to evaluate currentstrategies and consider changes in implementation ofalternative strategies, wherever deemed necessary, ifit ahs to control the TB scourge. There is a lot of scopefor health management research in TB controltoderive the most appropriate, effective, and feasibleorganizational structure and to test the adaptabilityfor other areas, paving way for uniform healthdelivery system in this diverse country.Close interaction between researchers,programme managers and policy makers will help tofine-tune and make midcourse corrections. Mid-termgoal for the programme have to be defined. Problemsin achieving these objectives have to be identified anda research agenda needs to be formulated to answerthe constrains identified. Research, by being linked tothe constrains and objectives, will always berelevant to TB control programme and the findingswould influence policy and practice.Operational research should become an integralcomponent of the programme management.REFERENCE1. Raviglione M C, Pio A. Evolution of WHOpolicies for tuberculosis control, 1948-2001.Lancet 2002; 359 (9308): 775-80.2. Adauto Castelo, Pedro A Mathiasi, RobertoLunescet al. The global challenge oftuberculosis: cost-effective and affordabletreatments. Pharmaco Economics 1995; 8(5):385-99.3. Bordia NL. National Tuberculosis Programme.Ind J Tub 1967; 14 (4): 183-85.4. Khatri OR, Frieden T R. The status andprospects of tuberculosis control in India. Int JTuberc Lung Dis 2000; 4 (3): 193-200.5. Khatri G R. The revised national tuberculosiscontrol programmer: a status report on first1,00,000 patients. Int J Tub 1999; 46: 157-66.6. Progress towards tuberculosis control,India,2001. Weekly Epidemiological Record2002; 77 (12): 89-93.7. Joint Tuberculosis Programme Review,India,February 2000. World healthOrganization, WHO, SEA-TB-224, 5 May 2000.8. Revised National Tuberculosis ControlProgramme. Operational guidelines fortuberculosis control. Central TB Division,Directorate General of Health Services, NirmanBhavan, New Delhi, India, 1999.9. S.Mayurnath, R.S. Vallishayee, M PRadhamani, R. Prabhakar. Prevalence study oftuberculosis infection over fifteen years, in arural population in Chingelpet District (southIndia), Indian J Med Res 1991;  93: 74 - 8010. K. Sytblo. The relationship between the risk oftuberculosis infection and the risk ofdeveloping infectious tuberculosis. Bulletin ofInternational Union against tuberculosis 1985;60 (3-4): 117 - 19.11. DeCock KM, Weiss HA. The globalepidemiology of HIV/AIDS. Tropical Medicineand International Healtth 2000; 5: A3-9.12. Swaminathan S, Ramachandran R, Baskaran G,Paramasivan CN, Ramanathan U, VenkatesanP et al. Risk of development of tuberculosis inHIV infected patients. Int J Tuberc Lung Dis2000; 4: 839-84413. CDC. Progress towards tuberculosiscontrol, India, 2001. MMWR, March 23, 2002; 77(12): 89-93.Figure 1: Organogram of the government health care delivery system for tuberculosis controlNational level(Deputy Director General - Tuberculosis)National Institutes(TRC, NTI, LRS, AIPH&H) < -State level(STO, STDC) <District level(DTO)Sub-district level (one per 500,000 population)(MO-TC, STS, STLS)Microscopy centre (one per 100,000 population)(LT)Primary health care level (one per 30,000 population)(PHC, CHC, Dispensary)Sub-centre level (one per 5000 population)(Sub-centres, treatment centres)1 1 7

Tuberculosis control strategies: Challenges to health management research

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Tuberculosis control strategies: Challenges to health management research

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