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RNTCP – Government TB Treatment Education & Care NSP

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. The RNTCP is responsible for carrying out the Government of India five year TB National Strategic Plans.

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) 2012 -2017

For the five year National Strategic Plan for 2012 – 2017, the vision of the government was for a TB free India through achieving Universal Access. This was to be through the provision of quality diagnosis and treatment for all TB patients in the community. This was a major policy change.

The policy change meant extending the reach of RNTCP services to all people diagnosed with TB, including those with drug resistant TB, as well as those seeking treatment in the private sector. The new policy also included improving the quality of existing RNTCP services.

The aim was to achieve the following targets by the end of 2015:

  • early detection and treatment of at least 90% of estimated TB cases in the community, including HIV associated TB
  • initial screening of all previously treated (retreatment) smear-positive TB patients for drug resistant TB and the provision of treatment services for multi drug resistant TB
  • the offer of HIV counseling and testing for all TB patients, and linking HIV infected TB patients to HIV care and support
  • successful treatment of at least 90% of all new TB patients, and at least 85% of all previously treated TB patients
  • the extension of RNTCP services to patients diagnosed and treated in the private sector.

Activities to achieve these targets

The RNTCP planed to achieve these targets by:

  • using rapid diagnostics for the diagnosis of TB and drug resistant TB
  • expanding services for the management of multi drug resistant TB
  • strengthening urban TB control
  • strengthening public-private mix initiatives
  • improving the quality of basic DOTS services
  • aligning with National Rural Health Mission supervisory structures.

The Standards for TB Care in India was produced in 2014 to help ensure a successful standard of diagnosis and treatment. The Standards for TB Care in India, set 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.

Private sector care for TB

Another government order in May 2012 made it compulsory for health care providers to notify every TB case diagnosed.  This was done with the aim of improving the collection of patient care information. It meant that in future all private doctors, caregivers and clinics treating a TB patient had to report every case of TB to the government.

Comments made in response to this move included concerns about enforcement of notification by private practioners;

“This is definitely a positive step forward. But, I am skeptical about the practical possibility in implementing the policy. Most private practioners consider themselves unaccountable to the government. .. The government should be clear about the action that will be taken in case of non compliance of the private practioners.”

There was also concern about whether when people are referred to the RNTCP from the private sector there would be a good enough service, and whether in practice TB treatment would be available.

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:32015 report on Indian Revised National TB Control Programme from Joint Monitoring Mission /index1.php?l http://tbcindia.gov.in/index1.php?lang=1&level=2&sublinkid=4161&lid=2809 

  • 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 was 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 MDR TB, was estimated to be Rs. 5825 crore ($1.17 billion) over the period 2012 – 2017. However, the Planning Commission of India 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/

Launch of the NSP 2017 – 2025

A major change then took place in India in 2017 with the launch of the NSP 2017 – 2025. This followed an announcement that the national goal was now the elimination of TB in India by 2025.

Read more

You can read more about TB in India

or TB treatment in India

or Drug resistant TB in India

Major Sources for RNTCP

2015 report on Indian Revised National TB Control Programme from Joint Monitoring Mission 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 2017 Revised National TB Control Programme Annual Status Report, New Delhi, 2017 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. 2015 report on Indian Revised National TB Control Programme from Joint Monitoring Mission /index1.php?l http://tbcindia.gov.in/index1.php?lang=1&level=2&sublinkid=4161&lid=2809 
4. Srivastava, K, “TB epidemic looms large with Rs 2,000 crore fund cut, erred policy”, dna, 10 January, 2015 www.dnaindia.com/