|Year : 2005 | Volume
| Issue : 4 | Page : 107-111
Revised national tuberculosis control programme (RNTCP) in India; current status and challenges
Navneet Singh, Dheeraj Gupta
Department of Pulmonary Medicine, PGIMER, Chandigarh., India
Additional Professor of Pulmonary Medicine, Postgraduate Institute of Medical Education & Research (PGIMER) Chandigarh-160 012.
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Singh N, Gupta D. Revised national tuberculosis control programme (RNTCP) in India; current status and challenges. Lung India 2005;22:107-11
| Introduction|| |
Control of tuberculosis (TB) in India has come a long way since the initiation of the National TB Programme (NTP) in 1962. Despite the establishment of more than 440 District TB Centers, the NTP suffered from several serious drawbacks including managerial weaknesses, inadequate funding, overreliance on chest radiographs, lack of standardized treatment regimens, low rates of treatment completion, and lack of systematic information on treatment outcomes. The cure rate was dismally low-only 30% of all patients were diagnosed, whom of only 30% were treated successfully.  This prompted the Government of India, in collaboration with the World Health Organization (WHO) to evolve a revised strategy for the control of tuberculosis in India. The Revised National TB Control Programme (RNTCP), an application of the WHO recommended Directly Observed Treatment, Short Course (DOTS) strategy was launched in 1992 with the objective of detecting at least 70% of new sputum positive TB patients and curing at least 85% of such patients.
The basic principles of RNTCP  are:
- Political commitment for ensuring adequate funds, staff and other key inputs.
- Establishment of diagnosis primarily by microscopic examination of specimens obtained from patients presenting to health care facilities.
- Regular and uninterrupted supply of anti-TB drugs in the form of a patient-specific box that contains the medicines for the entire course of treatment so that no patient is subjected to interruption of treatment for lack of medicines.
- Direct observation of every dose of treatment in the intensive phase and of at least the first dose in the continuation phase of treatment.
- Systematic monitoring, supervision and cohort analysis-one Senior Treatment Laboratory Supervisor (STLS) is responsible for organization of uninterrupted treatment and one Senior Tuberculosis Laboratory Supervisor for ensuring quality laboratory service for every 5,00,000 population.
Programme Expansion and Current Coverage
The initial implementation of RNTCP started in 1993 with a population coverage of 2.35 million at 5 sites in different states (Delhi, Kerala, West Bengal, Maharashtra and Gujarat). Its expansion continued in the following years with population coverage reaching 13.85 million in 1995. The phase of rapid expansion that occurred in 1998 has continued till date [Table 1] &[Table 2] and currently, more than 90% of India's population has been covered under RNTCP including full coverage of 26 States and Union Territories. It is expected that the entire country should get covered by the end of the current year.
Comparison with DOTS Programmes in Other Countries
RNTCP is the largest and the fastest expanding DOTS programme in the world and approximately 100,000 patients are being initiated on treatment every month. The WHO report on Global Tuberculosis Control in 2005  remarks that "India, the country with the greatest burden of TB, is also the country where the most dramatic advances are being made in DOTS expansion." In 1999, the Indian expansion of RNTCP accounted for 1/3 and in 2000 and 2001 for over 1/2 of the global increase in DOTS coverage.
Despite the rapid expansion, quality of services has been maintained and phased implementation of the programme is in part responsible for this. Infact, there has been a considerable improvement in the level of case detection and India has made a greater contribution to the global increase in case finding than any other country since 2000.
During 2004, sputum positive case detection and treatment success rates were 72% and 86% respectively-both being higher than their respective global targets. Improvement in treatment success rates since the implementation of RNTCP have lead to reduction in death rates by 7-fold from 29% to 4%  .
The improvement in cae detection and treatment has also been witnessed in extra-pulmonary and retreatment cases. In the third quarter of 2004, extra-pulmonary cases comprised 14% of all new case while re-treatment cases comprised 25% of all smear positive cases. 
RNTCP's progress has been remarkable not only because of the expansion in population coverage and case detection but also because it has been made at a lower than predicted cost. The budget per patient is lowest in India among all the countries that have a high burden of disease (US$ 34 vis-Mvis US$ 100200 for all such countries).
DOTS Providers-Government and Beyond
A major achievement of RNTCP has been the involvement of individuals and organizations other than the government employees and bodies.
1. Private Practitioners & Non Government Organizations (NGOs) - It has often been observed that practices of private health providers are associated with inappropriate diagnostic preferences, inaccurate interpretations of results of laboratory and other diagnostic tests, incomplete or non-disclosure of the disease(s) to patients, institution of inappropriate treatment and tendency to overtreat. With specific reference to TB and its control, in the past, private practitioners had a tendency to deviate from the recommended TB case management principles including sole reliance on chest radiography for diagnosis, infrequent use of sputum microscopy (both for diagnosis as well as monitoring of treatment) and prescription of inappropriate drug regimens (including incorrect combination or doses of drugs as well as inappropriate duration of treatment) resulting in poor treatment outcomes. , In addition, failure on their part to notify detected cases, maintain records properly or make an effort to trace treatment defaulters made the task of TB control by the government agencies more difficult.
However, it was soon realized that there was no getting away from the ground reality that majority of patients first approach a private health practitioner at the onset of an illness. In cases of tuberculosis, these rates have been reported to be as high as 86% in India  . This propensity of patients to dislike and not utilize public health facilities and instead approach services of private health providers, despite the latter being more expensive, could be partly responsible for less than-expected progress despite adequate governmental spending. 
A landmark study from Hyderabad  showed that collaboative effort between private practitioners and the government can help to implement DOTS effectively. A non-profit hospital covering a population of over 500,000 encouraged 358 allopathic and non-allopathic physicians practicing in the area to participate in tuberculosis detection and treatment by referring patients to the hospital. Though no financial incentives were offered, 59% of these practitioners referred patients to the hospital and 43% of all referred patients had tuberculosis. Diagnosis, treatment, and case and outcome definitions were performed as per DOTS policies-medicines and laboratory reagents being provided by the government. DOTS was administered either at the hospital or 30 other small hospitals operated by these private practitioners. This lead to a 4 fold increase in TB detection rate over the first 2-3 years of the project with 90% of new smearpositive patients and 77% of re-treatment patients being successfully treated.
Significant progress has been made subsequently in the area of involvement of private practitioners in RNTCP. The roles of private practitioners in the different aspects of RNTCP viz referral, provision of DOTS, functioning as designated paid/free microscopy centres (microscopy alone or with treatment) have been defined now  . To ensure smooth functioning, the roles of District Tuberculosis Centres as well as the Grant-in-Aid and Eligibility Criteria for the private practitioners have been simultaneously specified.
Similar guidelines have been issued in order to achieve uniformity in the involvement of NGOs.  The various schemes available for involvement of NGOs include Health Education and Community Outreach, Provision of DOTS, In-Hospital Care for TB patients, functioning as Microscopy and Treatment centre or as TB unit Model. Till date, over 1000 NGOs and over 5,000 private practitioners have been involved in RNTCP activities and the process of spreading this private-public mix to larger areas of the country is underway  .
2. Community Volunteers - Besides private health practitioners and NGOs, volunteers from the comunity can also make significant contributions to control of tuberculosis. These volunteers can be from any socio-economic strata or profession but one of the key determining factors remains their acceptability to the patient  . Their commitment as DOTS providers also needs to be ensured and supervision by district TB programme officials is usually done. A WHOGovernment of India (GOI) study from Haryana  reported that treatment success rate of new sputum smear-positive patients receiving DOTS from community volunteers was comparable with that of patients receiving DOTS from government health workers (78% and 77% respectively). The primary responsibility for returning late patients to treatment was with the staff of the District TB Centre in this urban model for community volunteer involvement and concerns were expressed whether it could be applied to rural settings or even urban centers with the volunteers given charge of tracing and returning late and/or defaulting patients to treatment. Formal guidelines with respect to involvement of community volunteers are likely to be issued only when the above mentioned issued get resolved with field studies carried out on a larger scale in the future. Financial compensation to the volunteers would remain an important component of such guidelines when issued.
3. Consultants - Appointment of consultants to monitor DOTS expansion and implementation has also met with considerable success especially in areas where difficulties were anticipated. Reduction in the median time required for initiation of DOTS services, higher rates of sputum conversion and higher treatment success rates were observed in areas where consultants were present in comparison to those without  . In addition to providing technical assistance to the state and district TB offices, these consultants also act as links between the national level and state/ district level programme staff  . However once the phase of rapid expansion in India is over and population overage approximates 100%, their role is likely to assume less importance.
4. Medical Colleges & Corporate Hospitals - Last but not the least has been the areas of involvement of hospitals other than those in the Public Health Department including hospitals of the Indian Railways, ESI hospitals and Port hospitals. National, State and Zonal Task Factors have been established in order to increase the involvement of medical colleges with RNTCP. Priority activities that can be undertaken by medical colleges include training cum-teaching of medical professionals and other staff for RNTCP, delivery of services of RNTCP, advocacy of RNTCP and operational research. Professors in medical colleges can not only serve as role models for practicing physicians but also sensitize medical students to the problem of TB control and this can lead to significant improvement in the level of involvement as well as commitment of medical professionals with RNTCP. The number of medical colleges and corporate health facilities participating in RNTCP have crossed 200 and 100 respectively , .
Challenges for Achievement of Optimal Programme Performance
One of the most important constraints for maintenance of quality TB services by RNTCP is shortage of staff resulting from its rapid expansion phase. Till the time additional technical staff gets recruited - a process that normally takes a long time in the government set up-the current staff can be redistributed to areas that are relatively understaffed and their capacity increased through training programmes run by expert consultants. Sustained political commitment is needed to ensure that the recruitment process is expedited and RNTCP remais adequately staffed at all levels.
Upgradation of existing TB laboratories and creation of new microscopy centres are part of the efforts to strengthen the TB laboratory network - an essential requirement of the expanding RNTCP. At present more than 1000 laboratories provide diagnostic facilities throughout the country. An External Quality Assessment (EQA) for sputum microscopy that is based on international guidelines has been adopted since 2004 for the microscopy laboratory network and it includes a random blinded crosscheck of routine slides each month , . Though unblinded rechecking of smear by STLS yields a 95 to 100% agreement with what was reported by laboratory technicians, blinded rereading/restaining at a national can lead to reduction in the false positive errors from 27% to 7%  .
Improvement in indicators of treatment associated parameters is of paramount importance in order to achieve betterment and even maintain established goals of case detection and treatment. It is therefore necessary to identify factors other than those related to drug therapy and drug resistance which could be affecting these parameters.
A recently published retrospective study from Delhi  (n=2938) showed that initial bacillary load can influence sputum conversion rates and treatment outcome of new smear positive pulmonary tuberculosis patients treated by DOTS. Sputum conversion rates among patients with sputum gradation of 3+ were 62.2% and 81.3% respectively at the end of 2 & 3 months. These were significantly lower when compared to rest of the patients (sputum gradations of 1+/ 2+) for whom conversion rates were 76.8% and 89.5% respectively. Cure rates were lower (76.6% vs. 85.1%) and failure rates were higher (7.7% vs. 4.5%) for patients with 3+ gradations of sputum. Further studies might be needed to investigate and confirm this finding and assess whether there is a need to separately categorize patients with higher bacillary load.
Other socioeconomic factors that have been identified in previous studies done among patients on DOTS in India include smoking with relapse  , alcoholism, old age and poverty with default ,, and malnutrition with death.  It is unclear to what extent these factors affect the functioning of RNTCP especially with respect to treatment related parameters, whether any form of intervention designed to identify (and if possible modify) some or all of them can lead to significant improvements in these parameters and if yes, whether such interventions are feasible under national programme conditions.
Treatment of multi drug resistant (MDR) cases ('DOTS PLUS') and utilisation of DOTS in patients with HIV-TB co-infection are areas that are likely to receive more attention once the rapid expansion phase of RNTCP is over. These areas require significantly higher financial inputs and infrastructure availabilities and yet treatment is associated with poorer outcomes. However, without adequate efforts in both areas, overall treatment success rates of TB may not improve and can even fall. RNTCP has collaborated with National AIDS Control Organization (NACO) and implemented a Joint Action Plan (JAP) since 2001 that now covers 14 states where the level of HIV prevalence is high. Service delivery coordination and cross referral is one of the most important activities of JAP. The Microscopy-cum DOTS centre of RNTCP and the Voluntary Counseling and Testing Centre of NACO are likely to be the key establishments in the process of treatment and referral. Carrying out of drug resistance surveillance (DRS) surveys and establishment of quality assured culture and drug sensitivity testing (DST) laboratory facility in large states along with provision of second line drugs for treatment of drug resistant cases are activities likely to be given more thrust as part of DOTS Plus Strategy. 
| Summary|| |
Though India occupies only 2% of the land area of the world, it holds the dubious distinction of having the most number of TB cases worldwide. As RNTCP's population coverage increases to the whole country, maintaining quality of service will be an important priority and this requires not only effective supervision and monitoring strategies but also recruitment of additional staff as well as improvement in the laboratory support for the expanding services. Efforts at increasing case detection as well as rates of treatment completion and cure will also play a crucial role and possibly determine the degree of success that RNTCP achieves in the control of tuberculosis in the years to come.
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[Table 1], [Table 2]