|Year : 2011 | Volume
| Issue : 3 | Page : 163-168
Evaluation of revised national tuberculosis control program, district Kangra, Himachal Pradesh, India, 2007
Surender Nikhil Gupta1, Naveen Gupta2
1 Epidemiologist Cum Faculty, Regional Health and Family Welfare Training Centre, Chheb, Kangra, Himachal Pradesh, India
2 Freelance Researcher in Epidemiology, Kangra, India
|Date of Web Publication||19-Aug-2011|
Surender Nikhil Gupta
Regional Health and Family Welfare Training Centre, Chheb, Kangra
| Abstract|| |
Background: The present evaluation study has been conducted with the following objectives: (i) To assess the treatment outcomes of revised national tuberculosis control program (RNTCP) in five microscopic centers of Kangra district under five tuberculosis units and (ii) To identify gaps and underlying contributing factors. Based upon the findings of (i) and (ii) we suggest appropriate measures to narrow down the existing gaps. Materials and Methods: We identified and interviewed health personnel involved, reviewed the documents and records pertaining to evaluation plan/guidelines, training records and reports generated by five tuberculosis units. We assessed the inputs, processes and outputs of the program across five tuberculosis units. We calculated the proportion of staff of various categories trained and internal quality control (case detection); availability of drugs, directly observed treatment short course (DOTS) providers, and supervision (case management) and information, education and communication (IEC), and funds distribution. (logic model). Result: Around 60%-88% of staffs of various categories trained with overall 25% gap of supervisory visits. In tuberculosis unit (TU) Nurpur, the discordant slides while cross-checking were 8% and 25%. The total proportions of sputum positivity are 5.1%; the highest in Kangra, i.e., 2.3% (national norms of 10-15%.). There was no full cross-checking of the positive slides despite internal quality in place. Increased numbers of the extra pulmonary tuberculosis cases (EPTB) are present in all TUs, as high as 61% in TU Dharamshala (Normal range 15%-20%). A gap of 20% DOT center exists-the least in (58%) in TU Nurpur. The awareness level in the TU Dehra is minimum (51%); more so in females and rural set up. Conclusion: RNTCP has successfully achieved all its targets in all the five TUs of Kangra District as per national norms despite several gaps. We recommend (i) filling of vacancies of medics and paramedics with reorientation trainings/refresher courses; (ii) conduction of supportive supervision by the seniors; (iii) investigation of cause of increased number of the extra pulmonary cases, and (iv) need of aggressive IEC activities.
Keywords: Extra pulmonary tuberculosis, Kangra, RNTCP, tuberculosis unit
|How to cite this article:|
Gupta SN, Gupta N. Evaluation of revised national tuberculosis control program, district Kangra, Himachal Pradesh, India, 2007. Lung India 2011;28:163-8
|How to cite this URL:|
Gupta SN, Gupta N. Evaluation of revised national tuberculosis control program, district Kangra, Himachal Pradesh, India, 2007. Lung India [serial online] 2011 [cited 2013 Dec 10];28:163-8. Available from: http://www.lungindia.com/text.asp?2011/28/3/163/83970
| Introduction|| |
Tuberculosis is as old as mankind and is mentioned in Vedas and Ayurvedic Samhitas. Caries spine has been found in Egyptian mummies in 3500 B.C. Robert Koch demonstrated that it was caused by the bacillus, called as Mycobacterium tuberculosis (Koch' bacillus).  The World Health Organization (WHO) has identified 22 high-burden Tuberculosis countries which collectively contribute 80 percent of the global burden of tuberculosis (TB). Tuberculosis is responsible for 5% of all deaths worldwide and 9.6% of adult deaths in the 15-59-year old-economic productive age groups.  Tuberculosis kills more women worldwide than all causes of maternal mortality. The case fatality rate of tuberculosis is high; approximately 50% of untreated cases die of the disease. One out of every three HIV/AIDS patients has TB. The latest WHO report on the global status of Multi-Drug Resistant Tuberculosis (MDR-TB) lists Henan Province, China as a "hot spot" for its high number of MDR-TB cases'. Around 5.3% of new TB cases in China are multi-drug resistant.
Asia carries the largest number of TB cases worldwide. Out of the 22 high-burden TB countries reported by the WHO, 10 are in Asia.  Three-fourths of TB patients in Asia develop active TB during their most productive years between the ages of 15 and 54 years old. India has the largest number of TB cases in the world, accounting for nearly one-fifth of the global burden.  In Himachal Pradesh, tuberculosis is quite wide spread in the poor socio-economic classes and the slum areas where women are the most sufferers. In the state, it occupies the seventh place (3.61%) in the women from the top 10 leading causes of the diseases  while in district Kangra; it is numbered on third place as 3%. So, it is one of the diseases of the public health importance in the district which needs to be studied in detail and evaluated all-round.  The key of this strategy is to cure TB through Directly Observed Treatment at a time and place convenient to the patient.  Case finding is passive detection by means of a patient-friendly and clinically efficient service based primarily on smear microscopy. The present evaluation study has been conducted with the following objectives: (1) to assess the treatment outcomes of RNTCP in five microscopic centers of Kangra district under five tuberculosis units and (2) to identify gaps and underlying contributing factors. Based upon the findings of 1 and 2, we suggest appropriate measures to narrow down the existing gaps.
| Materials and Methods|| |
Engaging all stake holders
All the stakeholders were first identified and their opinion, suggestions and consensus were obtained for this evaluation of RNTCP project through personal meetings and group discussions; with the chief medical officer, district tuberculosis officer, medical officer tuberculosis and medical officer and senior treatment supervisor/senior treatment laboratory supervisor. Through personal visits and group discussion details of the evaluation project was shared such as: (1) evaluation objective, (2) evaluation issues under assessment, (3) methodology to be adopted for the evaluation, (4) data collection methods, (5) data analysis, and (6) dissemination of results.
In-depth interviews using semi-structured questionnaires were developed for different health officials such as Chief Medical Officer (CMO), District Tuberculosis Officer (DTO), Medical Officer Tuberculosis Center (MOTC), Senior Treatment Supervisor (STS), Senior Treatment Laboratory Supervisor (STLS), laboratory technician at the MC, and DOTS provider at the DOT center. We interviewed them during the study. We discussed the different parameters/indicators of the RNTCP program with all the stake holders and also about the selection of the tuberculosis units and microscopic units.
Description of the RNTCP Program
Review of the documents
We reviewed the following documents on Tuberculosis: India RNTCP status report prepared by the Government of India, Directorate General of Health Services, Ministry of Health and Family Welfare, New Delhi. Tuberculosis India RNTCP performance report 2006; Operational Manual for District Tuberculosis Units; Operational Manual for Medical Officers tuberculosis; Operational Manual for STLS/STS; Reporting formats for DTC/TU (New case detection, sputum conversion, cure rate and personal medical records information (PMRI) peripheral health institution (PHI) report forms.
Evaluation of the program
Study Area: - District Kangra
The total population covered under RNTCP in the year 2001 was 13 38 536 (census 2001) The population has been divided in five tuberculosis units and 28 microscopic centers plus one microscopic centre conducted by Tibetan Delek hospital, Dharamshala-supervised by five STS (Senior Treatment Supervisor) and five STLS (Senior Tuberculosis Laboratory Supervisor). Five microscopic centers were selected for evaluation of the DOTS program. (1) DTC, Dharamshala, (2) Designated Microscopic Center (DMC) Kangra, (3) Designated Microscopic centre Dehra, (4) Designated Microscopic Centre), Nurpur, and (5) Designated Microscopic Centre, Palampur under the Tuberculosis Unit Dharamshala, Kangra, Dehra, Nurpur and Palampur, respectively. 
One microscopic centre was chosen from each of the five tuberculosis units at random for the study viz., Dharamshala, Kangra, Dehra, Nurpur and Palampur of Kangra district, Himachal Pradesh. Ten cases from each microscopic centre of corresponding TU were selected from second quarter to fourth quarter 2006 by lot method. In all 50 new slides positive patients were selected under the DOTS programme. These TUs were selected for study just because they are performing satisfactorily.
Data sources were primary data collection and the secondary data available from the records.
Data collection techniques and tools
Review of registers and records (Tuberculosis register, laboratory register, treatment cards) and Logic model for evaluation carrying three parts: Case detection, Case management and Information, Education and Communication (IEC) under RNTCP.
In depth interview using semi-structured questionnaires to District Tuberculosis Officer, Medical Officer Tuberculosis Center, Senior Treatment Supervisor, Senior Treatment Laboratory Supervisor, Laboratory technician at the DMC, and DOTS provider at the DOT center. They were interviewed during the study.
Data generated were analyzed by use of computer using Epi info and Excel.
| Results|| |
Evaluation of RNTCP
The findings of study are briefly listed. We took one microscopic centre each at random, from five tuberculosis units for evaluation, the results of which are shown in the following logic model [Table 1],[Table 2],[Table 3]. Under case detection evaluation, in all five TUs/DMCs, proportions of the trained medial officers are 88% with a gap of 12% excepting the medical officers TC (60%) with a further gap of 40%; laboratory technicians-80% with a gap of 20% and 10% gap of health workers. It has superimposed 25% gap of supervisory visits. Around 70% training sessions have been conducted. The laboratory equipments and reagents are in plenty supply in all TUs. The poor performing Tuberculosis Unit Nurpur has the discordant slides while cross checking as 8% and 25%. The total proportions of sputum positivity are 5.1%; the highest in Kangra--2.3%. There was no full cross-checking of the positive slides despite internal quality in place. Increased numbers of the extra pulmonary cases are present in all TUs, as high as 61% in TU Dharamshala (normal range 15-20%). Under case management evaluation, despite all five STS fully trained in TUs, abundance buffer stocks of the drugs and cards, a gap of 20% DOT centre exists--the least in (58%) in TU Nurpur. Around 96% of supervised treatment with median of 66% of supervisory visits has been conducted. Cure rate ranges in between 81% and 90% with the sputum conversion rate at the 3rd month in between 91% and 97%. Under IEC management evaluation, sufficient IEC materials and funds of Rs. 108 000/ for five TUs have been distributed. The awareness level in the TU Palampur is the highest (76%); more so in males and urban set up while that of TU Dehra it is minimum (51%); more so in females and rural set up.
|Table 1: Logic model for evaluation of Revised national tuberculosis control program (RNTCP), District Kangra, Himachal Pradesh, India, 2006. (case detection)|
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|Table 2: Logic model for evaluation of revised national tuberculosis program, Kangra, Himachal Pradesh, India, 2006 (case management)|
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|Table 3: Logic model for evaluation of Revised National Tuberculosis Program, Kangra, Himachal Pradesh, India, 2006 (IEC)|
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| Discussion|| |
This study was conducted for the evaluation of RNTCP in district Kangra from 2 nd to 4 th quarter, 2006. Its evaluation was based upon the quantitative logic model which consisted of three parts; Case detection, Case management and IEC model.
In the case detection evaluation, in the input indicator, in all five TUs 60% to 88% trained staffs of various categories; MO TC, medical officers, laboratory technicians and health care workers with overall gap ranging as low as 12% to as high as 60%. Shortage of the equipments, faulty microscopes and lack of the Continuation of Medical Education (CME) among the staff are the factors responsible for reduced number of the collection and examination of the slides, especially, in TU Palampur (0.88%). Overall on average, the supervisory visits done by the different officials in the given five TUs are 75%-a gap of 25% exists which needs to be bridged up either by new recruitment of the staff or stepped up facilitative supervision by the senior supervisors. In the process indicator, out of 10 planned sessions of trainings only seven (70%) have been done-a gap of 30% while the proportions of the suspected slides referred to the microscopy are 1.53% which is less as compared to the normal of 2%-3% of the program. The overall proportion of the slides cross checked is 20% which is above the normal figure of 10%-15% but only in TU Nurpur the discordant slides were 8% and 25%. The laboratory technician has been found to be deficient in doing his technical work as reported by STLS and secondly, the MO TC had the dual responsibility of attending outdoor patients during day hours and also night emergency duty. He was also concurrently working as a part time MO TC, with the result the programme suffered There were chronic shortages of staff of various cadres due to political interference in the shape of frequent transfers and deputations.
In the output indicator,The total proportions of sputum positivity are 5.1% as against the national norms of 10%-15%. Despite the internal quality control in place, there is no full cross checking of the positive slides and 10%-20% of the negative slides by the STLS in any of the TUs of the district, especially in TU Nurpur. The reason for the same was the late posting of the STLS and a part time working MO TC. There is no external quality control by the accredited laboratory of the other states. The highest positivity rate of the district Kangra (2.3%) was because of presence of the government medical college in the district.
In outcome indicator,on account of further cross checking with 50 random cases, there was downward trend of the disease transmission which was reflected by minimal default, failure and mortality rates and so are the transferred out and relapse rates. Maximum death rate (13%) (National standards being 0%-7%) was in TU Palampur, especially in the rural belted villages. This was because of long vacancy of MO TC of TU Palampur for one year. Other important findings in all TUs are the increased number of the extra pulmonary cases, as high as 61% in TU Dharamshala as against the normal range of 15%-20%. The reasons for their higher detection need to be explored further.
In the case management
In the input indicator, despite abundance buffer stocks of the drugs and cards, a median 85% of the DOTS centers with a gap of 20% are there. Minimal DOTS centers (58%) are in TU Nurpur due to the political considerations. Five STS are present and fully trained. DOTS centers need to be activated to the full strength. In process indicator,96% of the cases are getting the supervised treatment. The number of the supervisory visits by the different health officers/officials lies in the range of 0%-100%, the median being 66%. The lower down in the ladder of the health providers, the facilitative supervision and motivation/counseling also dwindles down owing to lack of communication and CME, rough and tough topography and shortage of the staff and skill. In Output Indicator,the successful completion of the NSP cases reflects in the range of 86%-93%, the median being 89%. The social stigmas of tuberculosis; distantly set up DOT centers and side effects of the anti tubercular medicines in the form of nausea, skin rashes and a few cases of jaundice in the area are some of the reasons for the increased defaulter rate in TU Dharamshala (6%). In Outcome Indicator,the cure rate rolls in the range 81%-90%; the lowest in TU Dharamshala as 81% (median being 86%) the sputum conversion rate at 3 rd month lies in between 91% and 97% (median being 95%). So, finally we observed that the outcome/impact indicators are in consistence with programme targets of the RNTCP in district Kangra.
In the IEC management
In input indicator, all five TUs/DMCs have sufficient IEC materials and funds of Rs. 108,000 INR to be equally divided among five TUs. In process indicator, sufficient IEC materials have been displayed in all 29 microscopic centers with Rs. 21,500/- spent for IEC activities from each TU. In output indicator, the awareness level in the TU Palampur is the highest (76%); more so in males and urban set up and the minimum being in TU Dehra (51%). The energetic IEC is the order of the day.
| Conclusion|| |
Despite several gaps identified as part of the evaluation such as (i) vacancies of medics and paramedics, (ii) gaps in knowledge in health personnel, (iii) Insufficient supportive supervision by the seniors, (iv) increased number of the extra pulmonary cases, and (v) increasing defaulter rate; RNTCP has successfully achieved all its targets in all the five TUs of Kangra District as per national norms.
Fill the vacancies of medics and paramedics. Reorientation trainings/refresher courses need to be started for the medical officers and other para medical staff.
| Recommendations|| |
Medical officer of tuberculosis unit, senior treatment supervisor and senior treatment laboratory supervisor must be regularly supervised.
Evolve a method to cross check the supervisory visit of the junior supervisors by the senior supervisors.
Explore the causes for the increased number of the extra pulmonary cases in the Kangra district.
Patient should be counseled about the importance of directly observed treatment and so as to avoid the social stigma and humiliation, DOTS should be provided at home by health providers, like multiple health workers/anganwari workers/village health guides.
| Acknowledgements|| |
We gratefully acknowledge the cooperation we received in the evaluation of RNTCP programme from the Offices of Directorate of Health Services, Shimla; Chief Medical Officer; District Tuberculosis Officer, Kangra at Dharamshala and patients and their families and numerous individuals in five tuberculosis units of Kangra, Himachal Pradesh. A special word of thanks is also due to guidory support and supervision from National Institute of Epidemiology, Chennai, India and Miss Shivani Gupta for active proof reading of the manuscript and suggestions.
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[Table 1], [Table 2], [Table 3]
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