TB control in Tamil Nadu: Scope for improvement
TRADITIONALLY, Tamil Nadu has had a well deserved reputation for excellence in health care. Political commitment, administrative drive and a sound health infrastructure and delivery system have ensured that the performance of this State is far superior to that of many others in the country. Is this true of Tuberculosis (TB) control as well?
There are 10 lakh TB patients in this State. Each one of them is capable of infecting 10-15 others. Here is a disease that kills more people than malaria or AIDS put together, but, illogically receives less attention than say, HIV/AIDS. The Government of Tamil Nadu implemented the Revised National Tuberculosis Control Programme (RNTCP) in small pockets initially (1999) and later (2001) across the State to tackle this menacing public health problem.
There are over 10 TB hospitals and sanatoria with eight of these institutions in the government sector under the control of the Director of Medical and Rural Health and the Director of Medical Education. There is a full-time State TB Officer. The Central Government assists the programme by supplying 100 per cent of drugs. The State finances the TB machinery.
An unbiased observer will say that here is a State with adequate means for good, if not excellent, TB control. Based on past performance, the expectation was that Tamil Nadu will become a model State. The reality is that Tamil Nadu is trailing behind other States, even those which are less than adequately endowed in terms of health infrastructure like Assam or Orissa.
What are the consequences? The estimated death rate from TB in India is 53 per lakh population. Given that the population of Tamil Nadu is about 621 lakhs, one can work out the appropriate grim calculations on the number of preventable deaths. But, can statistics tell us about jobs lost from ill-health, children orphaned, women socially stigmatised and abandoned or families pushed below the poverty line?
However, it must be said that after the sad slump in early 2001, the State TB machinery has made intense efforts to stop the downward trend in both case detection and treatment success rates. The latest figures indicate that the performance of the State is moving upwards steadily again and this is a heartening trend.
In an attempt to elicit the steps taken by the Government of Tamil Nadu to put TB control back on track, an interview was given by a panel of health department functionaries: The Secretary for Health and Family Welfare, the Director of Public Health (DPH), the Director of Medical Education (DME), the Director of Medical and Rural Health Services (DMS) and the State TB Officer (STO).
Dr. UMA KRISHNASWAMY: The performance of Tamil Nadu in TB control has fallen short of popular expectations. What are the reasons? There are of course signs of recovery now. What are the efforts being made to sustain this upward trend?
PANEL: Although there were a number of challenges, Tamil Nadu is now one among nine States covered under the RNTCP. TB diagnosis and treatment were already a part of the better developed public health services in the State. However, treatment delivery at field levels was not supervised. It took some time to ensure that treatment and follow-up were supervised by the health providers at the grass root level.
Efforts have been taken to involve all government health institutions at the primary, secondary and tertiary levels in the RNTCP. The process of filling up of staff vacancies in supervisory categories and at the field level have also been completed. This has had a positive impact.
The performance of the State has shown a steady improvement and has reached the national indicators as of the fourth quarter of 2002. More than 80,000 TB patients have been registered for treatment in 2002 alone, because of intense and focused supervision, prompt responses and corrective action at the State and Central levels and strong administrative and political commitment.
Since 2001, the RNTCP has been adopted by the State. Yet, there were hiatuses until recently even within government institutions in adopting the RNTCP and the DOTs (Directly Observed Treatment short course) strategy. Did this not affect the statistical validity of the State performance indicators? Unless there is a uniform methodology and reporting system, how can quality control checks or statistical analysis of pooled data be done?
This is an important issue. If case detection and patient outcome are to be improved, then institutions government and private should be encouraged to register patients under the RNTCP. All government health facilities in the State are now participating in the RNTCP.
The methodology for collecting data and reporting are uniform and devised by the Central TB Division. Quality control is an integral part of the programme and is carried out as per the protocol provided in the RNTCP.
Treatment for patients in the RNTCP is decentralised so that patients can receive their medication close to their homes. Treatment outcomes are therefore calculated for groups of patients registered in the sub-district or TB unit where they receive treatment. This data is analysed every quarter so that attention can be given to the units that are under performing. Treatment outcomes in Tamil Nadu are now on par with the national average.
Remarkably, India (and Tamil Nadu) is able to follow patient outcomes closely, produce and disseminate a quarterly summary about a month after the quarter ends and analyse cohorts of patients to determine whether targets are being met. The data is used to make policy decisions in a timely fashion. This is the reason that such care is taken to monitor the quality of the data and recording system. Without this quality, DOTS will not work.
There are other government institutions in the State catering to large segments of the population such as the Railways, ESI, CGHS, Port Trust, etc., which provide health services to their employees and their families. Most have not been brought under the umbrella of the RNTCP as yet. The Joint TB Review Programme India, February 2000, clearly stated that in these institutions, "results of diagnosis and treatment of TB are inferior to those achieved in the RNTCP". What steps have been taken at the State and Central levels to involve these organisations?
Other government institutions are also being progressively brought under the RNTCP umbrella. The Railways have already been involved. Similarly the ESI has also been involved through its regional hospitals and at the State level through its directorate. Modular training has been provided to medical officers, laboratory technicians and health staff in these institutions in the RNTCP. Hospitals and dispensaries have been identified and designated as microscopy centres and provided with binocular microscopes, laboratory consumables and patient-wise drug boxes. Patients are registered for treatment in the TB unit of their residence and monitored for follow-up and subsequent cure/completion.
Prisons in most of the districts are also implementing the RNTCP. The Neyveli Lignite Corporation (a public sector undertaking) is also implementing the RNTCP. Correspondence has been initiated to involve the CHGS and the Port Trust. As the RNTCP is a national programme, there are no blocks to involving government institutions fully into it.
Inter and intra sectoral coordination is vital in any national programme with both vertical and horizontal components of supervision and implementation. Are there concrete examples of coordination such as inter departmental meetings, reviews to pinpoint inadequacies and fix responsibility or the availability of say, a common data base?
Coordination is a priority and there is a high degree of intra-sectoral coordination at community, district, State, national and international levels. The programme in the TB units is reviewed by the District TB Officer (DTO). At the district level, the collector, who is also the chairperson of the District TB Control Society, reviews the programme with the DGO and the different wings of the health services in the district.
As the RNTCP is implemented in the six city Corporations in the State, the commissioners of the respective corporations and the corporation health officers are members of the local district TB Control Society and participate in the reviews with the collector.
At the State level, a review of DTOs is conducted by the STO. These reviews are attended by the Health Secretary, the DMS, the DPH, the DME, a representative from the Government of India and a consultant from the World Health Organisation technically assisting the programme.
In all these reviews, performance is evaluated at sub-district and district levels using a standardised analysis format developed by the Central TB division. The meetings are mounted and any corrective action is planned against a timeline.
Private practitioners play an important role in the management of TB with more than 50 per cent of patients approaching a private practitioner as the initial step. What are the strategies for facilitating private sector participation?
Private public partnerships are becoming increasingly important in controlling TB. However, to have a partnership, both partners must be strong enough to establish a collaboration. The priority in the initial years was to strengthen the public health services.
Efforts have since been initiated to facilitate private sector participation including the development of official policy guidelines that describe the options for collaboration. The Indian Medical Association with 130 branches in the State is helping private practitioners to be actively involved in the RNTCP. Lists of all large private health facilities in districts have been compiled and a drive is on to rope in these facilities.
There is no doubt that in Tamil Nadu, there is a strong political commitment to eradicate communicable diseases. I refer to the 15-point programme of the Chief Minister which explicitly spells out TB as a prime area of concern.
But, one asks, how uniform and sustained has this impetus been in administrative terms? One sees considerable, variations in district-wise performance indicators. For example, Chennai, Salem or Namakkal are performing reasonably well. But Madurai, Tiruvallur, Thanjavur or Erode are not. In light of this, what plan does the government have to increase the profile of TB control efforts in the districts individually and the State as a whole.
An analysis of the trends in performance of the RNTCP in the State shows a steady improvement district-wise. Many districts like Vellore, Salem, Trichy and others have a consistently good performance. As for Madurai, it is the first cohort reporting outcome and it is a small cohort. Tiruvallur has had special problems as it is a border district to Andhra Pradesh and there is a large migrant population within the district. Increased supervisory visits have already been carried out to increase control efforts in these districts and some improvement has been seen in the fourth quarter 2002 reports.
World TB day is observed on March 24.
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