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