agra presentation
TRANSCRIPT
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Revised National TB Control
Programme (RNTCP)
PPM DOTS in RNTCP
Central TB Division,
Ministry of Health and Family Welfare
Government of India
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Problem of TB 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: ~2.5 million people with HIV;
About 5% of TB patients estimated to be HIV positive
MDR-TB in new TB cases 3%
Substantial socio- economic impact
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0
200
400
600
800
1000
1200
Qtr1-94
Qtr3-94
Qtr1-95
Qtr3-95
Qtr1-96
Qtr3-96
Qtr1-97
Qtr3-97
Qtr1-98Qtr3-98
Qtr1-99
Qtr3-99
Qtr1-00
Qtr3-00
Qtr1-01
Qtr3-01Qtr1-02
Qtr3-02
Qtr1-03
Qtr3-03
Qtr1-04
Qtr3-04
Qtr1-05Qtr3-05
Qtr1-06
Qtr3-06
Quarter/Y
ear
Population covered (millions)
Total
patien
ts
treated
Popula
tion
co
ver
age(inmillion
s)
Po
pula
tionin
India
cov
ere
dun
derD
O
TSan
d
Tub
erculo
sisP
atien
tsputon
treatmen
teach
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Annualized New Smear-Positive Case Detection Rate
and Treatment Success Rate in DOTS areas, 1999-2007
Population projected from 2001 censusEstimated no. of NSP cases - 75/100,000 population per year (based on recent ARTI report)
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Qtr1-99
Qtr2-99
Qtr3-99
Qtr4-99
Qtr1-00
Qtr2-00
Qtr3-00
Qtr4-00
Qtr1-01
Qtr2-01
Qtr3-01
Qtr4-01
Qtr1-02
Qtr2-02
Qtr3-02
Qtr4-02
Qtr1-03
Qtr2-03
Qtr3-03
Qtr4-03
Qtr1-04
Qtr2-04
Qtr3-04
Qtr4-04
Qtr1-05
Qtr2-05
Qtr3-05
Qtr4-05
Qtr1-06
Qtr2-06
Qtr3-06
Qtr4-06
Qtr1-07
Qtr2-07
Qtr3-07
Qtr4-07
Annualised New S+ve CDR Success rate
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Year Milestones
1993 RNTCP started in pilot districts
1995 PPM model started in Hyderabad (NGO Hospital)
1997 National consensus conference of Medical Colleges
2000-2003 PPM models in Delhi, Kannur, Kollam, Mumbai, Tea-gardens of north-east
2001 Schemes for involvement of NGOs in RNTCP published
2002 Schemes for involvement of Private Practitioners (PP) in RNTCP published
2002 National workshop of medical colleges: seven nodal centres identified
2002-2003 PPM activities initiated in all the RNTCP states
2003 Intensified PPM scaling up began in 12 urban sites
2003-2004 Initiatives to involve other Government Departments, Public Sector Undertakings
2004 Declaration by national IMA to support RNTCP
2005 IAP guidelines, Urban DOTS GFATM projects, expansion of intensified PPM
2007 17,000 private practitioners, 250 Medical colleges, 2500 NGOs and 150 corporatehouses involved
RNTCP: Major milestones in PPM DOTS
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The New Global Strategy to Stop
TB
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Public-Private Mix (PPM) DOTS
PPM DOTS is a strategy to diagnose and treat
TB patients reporting to all sectors of health care
under DOTS strategy through a mix of differenttypes of health care service providers
PPM DOTS has been defined by WHO as
strategies that link all entities within the
private and public sectors (including healthproviders in other governmental ministries)
to the national TB programme for DOTS
expansion.
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ISTC
Focuses on TB care aswell as control
Supported by a broadinternational consensus
Presents an evidence
base Applies to all
practitioners and ismore relevant to theprivate sector
Serves as a focus of aglobal campaign toimprove TB care andcontrol
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Public sector
Provides
training/supervision
drugs/supplies/honorariu
m Notifies TB cases
Retrieves patients who
interrupt treatment
Other sectors
Refer/Diagnose/treat TB cases
Inform public sector about
TB patients/interruption of treatment
Follow
RNTCP guidelines
NGO/PP guidelines
Roles of public and private sectors in
PPM DOTS
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Achievements in PPM
3000 NGOs involved under RNTCP
~17,000 Pvt. practitioners involved under RNTCP
261 Medical Colleges following DOTS strategy
150 Corporate Houses participating in RNTCP
Involvement of professional bodies
IAP involved in development of Pediatric guidelines 2005
IMA actively collaborating in 167 districts/ 6 states under Rd 6
GFATM Project Indian Medical Professional Association Coalition against TB
(IMPACT) established in March 2007
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Intensified PPM DOTS sites
14 intensified PPM sites
Pilot Site State
Ahmedabad Gujarat
Bangalore Karnataka
Bhopal Madhya
Pradesh
Bhubaneswar Orissa
Chandigarh Chandigarh
Chennai Tamil Nadu
Delhi Delhi
Jaipur Rajasthan
Kolkata West Bengal
Lucknow Uttar Pradesh
Patna Bihar
Pune Maharashtra
Ranchi Jharkhand
Thiruvanthapura
m
Kerela* Additional sites
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14 intensified urban PPM districts( 3rd qtr2006 to 2nd qtr2007): Summary of
Contribution by different health sectors
61.2% 61.9%64.6%
71.8%
4.8%3.6%
3.5%
25.7% 24.5% 18.0% 5.9%
8.6%
5.8% 7.2% 7.0%11.5%
1.8%
0.3%
0.2%0.2%0.4%
5.2% 2.5% 6.5%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
TB suspects referred All S+ cases diagnosed New S+ cases detection No. of Patients provided
DOT
Health dept Govt, other than health Medical Colleges Corporate Private NGO
N=35658 N=49674 N=26321 N=76028
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Initiatives to Involve Medical Colleges
Consensus conference held 1997
Workshop of professors 2001
Workshops in States / Medical Colleges from 2002 onwards
National/Zonal/State Task MC
Forces created
Core Committees in MCs
RAJASTHAN
ORISSA
GUJARAT
MAHARASHTRA
MADHYA PRADESH
BIHAR
KARNATAKA
UTTARPRADESH
ANDHRAPRADESH
JAMMU &KASHMIR
ASSAM
TAMIL
NADU
CHHATISGARH
PUNJAB
JHARKHANDWEST
BENGAL
HARYANA
KERALA
UTTARANCHAL
ARUNACHAL PRADESH
HIMACHAL PRADESH
MANIPUR
MIZORAM
MEGHALAYA
NAGALAND
TRIPURA
SIKKIM
GOA
A&N ISLANDS
D&N HAVELI
PONDICHERRY
LAKSHADWEEP
DELHI
West Zone
East Zone
South Zone
North Zone
North-East Zone
ORISSA
#
#
#
#
#
#
#
Guwahati
Kolkata
Vellore
Chandigarh
AIIMS,Delhi
Jaipur
Mumbai
Medical Colleges as
RNTCP Nodal centres
RG Kar Medical College, CalcuttaLokmanya Tilak Municipal Medical College and Hospital, MumbaiSMS Medical College, Jaipur
All India Institute of Medical Sciences, N DelhiPost Graduate Institute of Medical Education and Research, ChandigarhChristian Medical College, Vellore, Tamil NaduGuwahati Medical College, Guwahati, Assam
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PPM DOTS
Systematic process in involvement Sensitization of administrators and opinion leaders
Orientation of RNTCP staff on PPM DOTS
Listing of PPM health care providers Identification/verification of PPM facility
Sensitisation of PPM providers
Training of PPM providers Signing of RNTCP schemes (Memorandum of Understanding-
MoU)
Start of service delivery
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Tools for PPM DOTS
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RNTCP guidelines
for the involvement
of NGOs (2001)
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RNTCP PPM DOTSadvocacy kit (2005)
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Training module for
private medical practitioners
Concise module
6 hours training
1 day X 6 hours
2 days X 3 hours
3 days X 2 hours
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Involvement of NGOs in RNTCP
There are 5 Schemes for collaboration
with NGOs
Scheme 1- Health education & community
outreach
Scheme 2- Provision of DOT
Scheme 3- In-hospital care for TB disease
Scheme 4- Microscopy & Treatment centre
Scheme 5- TB unit model
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PP schemes
1. Referral services
2. Provision of Directly Observed Therapy
3a. Designated Paid MC microscopy only.3b. Designated Paid MC microscopy and
treatment.
4a. Designated MC microscopy only.
4b. Designated MC microscopy and treatment.
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NGO Involvement in RNTCP in India
(year wise)
NGO
150
300
512
1222
2046
2263
0
500
1000
1500
2000
2500
2001 2002 2003 2004 2005 2006
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PP Involvement in RNTCP in India
(year wise)
PP
500900
1500
5518
10714
14674
0
2000
4000
6000
8000
10000
12000
14000
16000
2001 2002 2003 2004 2005 2006
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NoofNGOs
264 261
238
214207
166
131
114 10598
92
69 67 63 61 57 56
0
50
100
150
200
250
300
Ma
haras
htra
Gujarat
Tam
ilNa
du
Uttar
Pra
desh
Punjab
Karna
taka
Rajas
than
An
dhra
Pra
desh
Wes
tBengal
De
lhi
Man
ipur
Jhark
hand
Bihar
Assam
Kera
la
Orissa
Ma
dhya
Pra
desh
State*-wise distribution of NGOs
(3rd qtr2007)
*Only states with more than 50 NGOs involved are presented in the slide
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State*-wise distribution of PPs
(3rd qtr2007)
NoofPPs
4736
4307
1385
1006 972
730686
469391 353 346 305 280 256 231 195 169
0
500
1000
1500
2000
2500
3000
3500
4000
4500
5000
Gujarat
Maharashtra
Karnataka
Kerala
TamilNadu
Punjab
UttarPradesh
Rajasthan
Delhi
Haryana
WestBengal
MadhyaPradesh
AndhraPradesh
Assam
Chhatisgarh
Chandigarh
Bihar
*Only states with more than 150 PPs involved are presented in the slide
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Challenges - PPM DOTS
Public sector related Lack of interest / experience in dealing with other sectors
Lack of faith in the capacity of private sector
Private practitioner related Large and unorganized private sector Lack of faith in Public sector health programmes
Low priority for carrying out public health programmes
Patient related Contradicting information from health sectors/systems Lack of trust in the quality of care provided by public sector
Issues of stigma and confidentiality