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RNTCP – Government of India TB Treatment & Care

The RNTCP in India

The large scale implementation of the Indian government’s Revised National TB Control Program (RNTCP) (sometimes known as RNTCP 1) was started in 1997. The RNTCP was then expanded across India until the entire nation was covered by the RNTCP in March 2006. At this time the RNTCP also became known as RNTCP II. RNTCP II was designed to consolidate the gains achieved in RNTCP I, and to initiate services to address TB/HIV, MDR-TB and to extend RNTCP to the private sector. RNTCP uses the World Health Organisation (WHO) recommended Directly Observed Treatment Short Course (DOTS) strategy and reaches over a billion people in 632 districts/reporting units.

An RNTCP centre

An RNTCP centre

With the RNTCP both diagnosis and treatment of TB are free. There is also, at least in theory, no waiting period for patients seeking treatment and TB drugs.

The initial objectives of the RNTCP in India were:

  • to achieve and maintain a TB treatment success rate of at least 85% among new sputum positive (NSP) patients
  • to achieve and maintain detection of at least 70% of the estimated new sputum positive people in the community

New sputum positive patients are those people who have never received TB treatment before, or who have taken TB drugs for less than a month. They have also had a positive result to a sputum test, which diagnoses them as having TB.1Mukherjee, A “Outcomes of different subgroups of smear-positive retreatment patients under RNTCP in rural West Bengal, India”, Rural and Remote Health www.ncbi.nlm.nih.gov/pubmed/19260766

National Strategic Plan (NSP) & Standards for TB Care in India

The work required by the RNTCP is set out by the Government of India in the National Strategic Plan 2012 – 2017. In addition to implementing the NSP 2012 – 2017, the Government of India had also in 2014 agreed the Standards for TB Care in India, which sets out the standard of TB treatment in India and TB testing & diagnosis in India that should be provided by the RNTCP in all parts of India.2Standards for TB care in India www.searo.who.int/india/publications/en/ This has subsequently been endorsed by the Ministry of Health and Family Welfare. Among other points this acknowledged that patients would be treated by private providers, rather than simply demanding that unwilling patients should be referred to the public sector.

The Government of India had also in 2014 adopted, with all Member States of the WHO, the End TB Strategy. The End TB strategy, together with these other initiatives, effectively called for a major transformation of India’s current approach to tackling TB.

The Joint TB Monitoring Mission (JMM)

Members of the Joint Monitoring Mission of the RNTCP 2015

Members of the Joint Monitoring Mission of the RNTCP 2015

The Joint TB Monitoring mission (JMM) of the RNTCP brought together a number of national and international experts and organisations in 2014, to generally review the progress, challenges, plans and efforts of the RNCTP to control TB. The implementation of the NSP 2012 – 2017 was one of the areas looked at.

The Implementation of the NSP 2012 – 2017

The JMM acknowledged India’s remarkable achievements in TB control over the previous ten years.¬† This included testing more than 80 million people, detecting and treating 15 million TB patients, and saving millions of lives as a result of the efforts of the RNTCP. However, they also said that overall:

“the implementation of the NSP for 2012 – 2017 is generally not on track: projected increases in case detection by the RNTCP have not occurred, vital procurements are delayed and many planned activities have not been implemented. Also, of the recommendations made by the JMM 2012, about two thirds have not been fully implemented.”

Problems highlighted by the JMM report

The very extensive JMM report highlighted a number of problems with the work of the RNTCP. These included:3Leaked: draft 2015 report on Indian Revised National TB Control Programme from Joint Monitoring Mission www.tbonline.info/posts/2015/7/23/leaked-draft-2015-report-indian-revised-national-t/

  • There is a huge deficit in the TB program, and in order to reach the ambitious goals set by the program, an additional fund of 750 crores is needed.
  • The RNTCP was criticized for its continued use of a thrice weekly intermittent¬† regimen and initiation of treatment without knowing the resistance profile of the patients, which contributes to the amplification of resistance.
  • Procurement & supply chain management continue to be a problematic area with delays in procurement of GeneXpert, bad storage conditions and limited capacity of states on procurement in case of emergencies. The report specifically mentions the 10 month stock outs of GeneXpert cartridges in Andhra Pradesh.
  • For people having HIV-TB co-infection, integration of HIV-TB departments is still very slow.
  • Daily anti-tuberculosis treatment and initiation of Isoniazid Preventative Therapy for PLHIV has not started yet. GeneXpert is still not being used as the initial diagnostic tool for PLHIVs.
  • The lack of engagement of the the program to collaborate with the massive private sector, that is the first point of contact with healthcare for almost 70% of the TB patients, is still a huge gap.
  • Certain policy revisions have been done by the RNTCP, but the actual implementation of the changes is being held up by lack of decision making especially at central level of the MoH.

Recommendations made by the JMM report

The report gives extensive recommendations for each part of the report, and these include:

  • A significant increase in government funding for TB control. RNTCP will need 1500 crores/year to achieve the targets of the NSP and achieve the goals of the END TB strategy.
  • All patients should receive care based on the “Standards for TB Care in India”.
  • The Ministry of Health should ensure that private sector TB patients receive early TB detection, appropriate treatment, sustained adherence support and a reduction of their out of pocket expenses.
  • There is a need for a high level sustained national campaign on TB: “TB Free India/TB Mukt Bharat”.

Budget Cuts for the NSP 2012 – 2017

The overall budget required in 2012 – 2017 to achieve the Universal Access vision, to save 750,000 lives from TB, and to control MDRT TB, was estimated to be Rs. 5825 crore ($1.17 billion) over the period 2012 – 2017. However, the Planning Commission of India has so far only approved Rs. 4500 crore ($900 million). These budget cuts have been widely criticised and in January 2015 a warning letter was submitted to the government signed by TB officers of all states and Union territories. One doctor said:

“There is always a shortage of TB drugs, lack of labs, slow diagnostic tools, inadequate management of treatment and lack of trained personnel. Moreover, since we have failed to give the existing staff their salary dues they are demoralised”4Srivastava, K, “TB epidemic looms large with Rs 2,000 crore fund cut, erred policy”, dna, 10 January, 2015 www.dnaindia.com/

Read more

You can read more about TB in India.

Major Sources for RNTCP

Draft 2015 report on Indian Revised National TB Control Programme from Joint Monitoring Mission www.tbonline.info/media/uploads/documents/jmmdraft2015.pdf

Revised National Tuberculosis Control Programme Guidelines on Programmatic Management of Drug Resistant TB (PMDT) in India www.tbcindia.nic.in

Revised National Tuberculosis Control Programme National Strategic Plan 2012-2017

Standards for TB Care in India www.tbcindia.nic.in

TB India 2015 Revised National TB Control Programme Annual Status Report, New Delhi, 2015 www.tbcindia.nic.in

References

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1. Mukherjee, A “Outcomes of different subgroups of smear-positive retreatment patients under RNTCP in rural West Bengal, India”, Rural and Remote Health www.ncbi.nlm.nih.gov/pubmed/19260766
2. Standards for TB care in India www.searo.who.int/india/publications/en/
3. Leaked: draft 2015 report on Indian Revised National TB Control Programme from Joint Monitoring Mission www.tbonline.info/posts/2015/7/23/leaked-draft-2015-report-indian-revised-national-t/
4. Srivastava, K, “TB epidemic looms large with Rs 2,000 crore fund cut, erred policy”, dna, 10 January, 2015 www.dnaindia.com/