Health and Development Initiative-India, (www.healthinitiative.org), publishes 'TB News from India' once every two months. The objective of newsletter is to highlight issues related to Tuberculosis and HIV/AIDS control in India and enlist political, public, professional and administrative support for its cause. Health and Development Initiative-India is a not-for-profit organization and the news items have been quoted from various sources for fair use and in public interest. Reproduction of the material published is welcome provided a reference is made to the original source of the news item and 'TB News from India.

Editorial note:  

Equity in access to DOTS is the critical issue

The National Health Policy of India-2002 (NHP-2002) while describing the current TB situation in country makes the following observations-"In respect of TB, the public health scenario has not shown any significant decline in the pool of infection amongst the community, and there has been a distressing trend in the increase of drug resistance to type of infection prevailing in the country". These disturbing remarks merit an earnest discussion.

India has embarked upon an ambitious project to provide Directly Observed Treatment-Short course (DOTS) services. DOTS services are now available to more than fifty percent of Indian population and are anticipated to reach the entire population of the country by the end of 2005. However all those who are closely watching the spread of DOTS are unlikely to be satisfied merely with its geographical expansion. Their fundamental apprehension is whether DOTS services are reaching the poor, vulnerable and underprivileged.

NHP-2002 takes notice of uneven attainment of health indices in the country across the rural urban divide. The policy document notes "access to, and benefits from, public health system have been very uneven between the better-endowed and more vulnerable sections of society. This is particularly true for women, children and socially disadvantaged sections of society".

The policy acknowledges that existing public health infrastructure is far from satisfactory. It says " as a result of such inadequate public health facilities, it has been estimated that less than 20 percent of the population, which seek OPD services avail of such services in public hospitals. This is despite the fact that most of these patients do not have means to make out-of-pocket payments for private health services except at the cost of other essential expenditure for items such as basic nutrition".

The policy makes a special reference to 'meagre' public health services in urban areas. The urban population in the country is presently as high as 30 percent and likely to go up to around 33 percent by 2010. It recognizes that urban health services do not percolate to unplanned habitations and migratory population.

The policy admits that public health investment in the country has declined over the years. The aggregate expenditure in Health sector is 5.2 percent of Gross domestic Product (GDP) and out of this only 17 percent is public health spending, the balance being out-of-pocket expenditure. In fact the current annual per capita public health expenditure in the country is no more than Rs 200 (US $ 4).

The constraints under which Revised National Tuberculosis Control Programme (RNTCP) is working in India are far bigger than those listed above. A few reports have appeared in the media from time to time about misappropriation of RNTCP funds. The infamous case in which these funds were diverted in a Rajasthan district to buy a laptop computer and an air-conditioned car for a senior bureaucrat does not inspire any confidence. (http://www.healthinitiative.org/html/tbnews/archives/janfeb2k3.htm#2)

While it may be the time to pat our backs for our success in rapid expansion of DOTS in the country, it is not yet the time to rest on our laurels. When delegates assemble in December 2003 for the 'Second Stop TB Partners' Forum' in New Delhi, the performance of DOTS services in India will come under close scrutiny. The world is keenly watching as to how India manages to deliver DOTS services to a tribal woman in a remote inaccessible community, to a jobless HIV positive man living in a spread-out urban slum, to a factory worker who works in shifts and has no access to health care or to the child of a couple which keep on migrating from place to place in search of job or food. The world community will also carefully scrutinize how we integrate RNTCP and National AIDS Control Organization (NACO) activities and reign in the private health care sector to provide DOTS services.

The triumph of DOTS in India is crucial to global TB control effort. For DOTS to succeed in India equity in access to DOTS services is a critical issue.

DOTS Treatment Strategy Helps Fight Tuberculosis in India
(Voice of America News, 26 September 2003)

The World Health Organization says a treatment strategy is stemming tuberculosis in India, and saving tens of thousands of lives.

India has the highest number of tuberculosis cases in the world. The figures are staggering. In India, 1.8 million people develop tuberculosis every year, and 1,000 people die every day, or one every minute.

The disease, despite being curable, ran rampant in India because most illiterate and impoverished patients could not afford the recommended 6-month treatment. Many stopped taking the drugs halfway through the treatment, and as a result, tuberculosis recurred in a more deadly, drug-resistant form.

Five years ago, the Indian government and the World Health Organization began a large-scale approach called "Directly Observed Treatment," or DOTS, which has been successful in other countries.

Leopold Blanc is a WHO coordinator for tuberculosis control. He recently visited five Indian states and is upbeat about what he found, saying the new strategy seems to be working. "The patient is properly diagnosed," said Mr. Blanc. "There are drugs available free of charge. The patient treatment is monitored carefully. There is regular monitoring of what is going on. Reports are sent up to the national level. And, I think these are the very, very important elements." Health experts say the cure rate has increased dramatically. WHO expert Fabio Luelmo estimates 450,000 Indians will be saved by the end of this year.

"Mortality is being reduced already," he said. "And certainly transmission is being reduced, and, therefore, the children in the next generation will have much less tuberculosis than in this generation."

Right now, the program covers about three-quarters of India's one billion-plus population. WHO is urging the government to expand the program to the rest of the population to completely wipe out the disease. WHO officials say, if the program continues on the right track, India could cut the incidence of tuberculosis by half in six-to-seven years.

Private participation in TB control mooted in Kerala
(By M. Dinesh Varma, The Hindu October 3, 2003)

The Government in South Indian State of Kerala is understood to be considering a proposal by the Indian Medical Association (IMA) to engage private hospitals and practitioners in the on-going Revised National Tuberculosis Control Programme (RNTCP) in the State.

The IMA, had in a project, proposed to set up district task forces to coordinate activities, sensitise and provide training for doctors in the private sector, supervise record keeping and generate reliable statistics. According to Government estimates alone, over 30 per cent of TB patients are treated at private hospitals. There are 400,000 TB patients already existing in the State. It is estimated that there are roughly 30,000 new TB cases annually. Around 100,000 of the affected population are sputum positive cases, which are the most infectious in the community.

The IMA is pointing to the success in Kannur and Pathanamthitta, where private participation was carried out on an experimental basis. Dr. R V Asokan IMA spokesman said the participation of private hospitals in Punalur had resulted in higher detection and excellent cure rates among the TB population. ``In fact, Punalur is the only place in the country to achieve full saturation levels vis-à-vis the participation of all the private hospitals in the programme,'' he said.

In Kannur, case detection rates had improved by 15 per cent after private hospitals and laboratories were included in the programme, he said.

The Government had given its approval in principle for the IMA project outlining an action-plan for extensive involvement of private hospitals in the RNTCP at a meeting chaired by the Health Secretary, K. Ramamoorthy.

``The IMA will act as a catalyst and ensure the full participation of private hospitals in the initiative,'' R.V. Asokan, told The Hindu. However, the formal launch of the `public-private' mix to diagnose and cure tuberculosis patients in the State has been postponed from the scheduled October 2.
(Read the complete story at: http://www.hindu.com/2003/10/03/stories/2003100305870400.htm)
 

Anti-TB programme in entire State of Haryana from Nov 1
(Ruchika M. Khanna, The Tribune Chandigarh October 12, 2003)

The Haryana Health Department is all set to launch the Revised National Tuberculosis Control Programme (RNTCP) in 12 districts of the state on November 1, Haryana Day.

Officials in the department say that they aim to start the programme in the districts of Ambala, Kurukshetra, Kaithal, Panipat, Rohtak, Hisar, Bhiwani, Jhajjar, Rewari, Fatehabad , Sirsa and Mahendragarh on November 1, and thus cover all districts in the state under the RNTCP.

The programme was launched in the districts of Panchkula and Yamunanagar on October 3, and the department had made a national record by launching RNTCP in these two districts in the short time of three months.

The RNTCP was launched by the Union Health Ministry in 1992 after the National Tuberculosis Control Programme (NTCP) failed to meet the desired results as the number of deaths due to tuberculosis and the dropout/default rate of patients continued to increase, whereas the cure rate showed little signs of improving. This programme has been launched in the state with the assistance of the World Health Organisation (WHO) and USAID, which have given an assistance of Rs 31 crore for a period of five years beginning 2003.

The programme was first launched in the districts of Gurgaon, Faridabad and Sonepat in April 2000, while two more districts of Karnal and Jind were included in the RNTCP in March earlier this year. Health Department officials say that the cure rate of tuberculosis in the districts of Gurgaon, Faridabad and Sonepat, ever since it was launched, is about 81 per cent and the patient dropout rate/default rate has also been reduced to 12 per cent from the earlier rate of 40 per cent.

Says the State TB and Leprosy Officer, Dr Vijay Garg, "More than 4,000 DOT (Directly Observed Treatment) centres, about 120 microscopy centres and 26 TB units are being created in the 12 districts that will be included in the programme from the next month."

Plan to open 10 more centres to check TB in Chandigarh
(Pratibha Chauhan, The Tribune, Chandigarh, July 18, 2003)

There is a proposal to open 10 new directly observed treatment (DOT) centres under the Revised National Tuberculosis Control Programme (RNTCP) in city slums where 60 per cent of the tuberculosis patients are concentrated.

A majority of the 9,000 tuberculosis patients in the city are residing in slum colonies within the city, while a small fraction belongs to the rural slums like Hallo Majra and Daddu Majra. "In order to further strengthen our services, we have sent a proposal to the Municipal Corporation for setting up 10 DOT centres in slums having highest concentration of TB patients," says a health official.

Health officials had met the Municipal Commissioner, Mr M.P. Singh, two days back to discuss the issue. "We already have 11 microscopy centres, two treatment units and 67 DOTS centres covering the entire city, but for effective coverage of slums, we will set up 10 more centres," says Dr P.K. Shridhar, in charge of the programme. Though DOTS centres are located in the vicinity of these slums, a need is being felt to make inroads into these areas, where the population is at high risk of contracting the infection. Health officials are hopeful that they will be able to set up new DOTS centres within a month.

Health officials involved with the implementation of the RNTCP point out that it is basically the clustering of various factors like poverty, illiteracy and malnutrition, which makes the slum population more vulnerable to TB infection. While the incidence of tuberculosis amongst male and female population of the city is almost the same, about 10 per cent of the TB patients are children.
(Read the complete story at: http://www.tribuneindia.com/2003/20030719/cth3.htm)

Prescribe anti-TB drugs only under new guidelines
(The Tribune News Service, Sangrur September 17, 2003)

After the failure of the National Tuberculosis (TB) Control Programme started in 1962, the Punjab Government does not want to take any chances in the newly launched Revised National TB Control Programme (RNTCP) in checking the spread of TB.

The Punjab Government has recently directed all government doctors not to prescribe any anti-TB treatment other than those prescribed under the RNTCP guidelines. This has been done as reports of prescribing different kinds of treatment by government doctors in district hospitals have been received.

Mr D.S. Jaspal, Principal Secretary, Health and Family Welfare, Punjab, through a letter to the authorities concerned recently, said that the District Tuberculosis Officers (DTOs) should not be given any other work except the RNTCP and their work should not be given to anyone else.
(Read the complete story at: http://www.tribuneindia.com/2003/20030917/punjab1.htm)
 

India gets $ 2.6 million from Global Fund to fight TB
(Times News Network, October 21. 2003)

India has received US $ 2.6 million in grant from the Global Fund for a two years period to fight AIDS and TB.

Meeting in Thailand the Board of the Global Fund last week approved $ 623 million in two-year grants to different countries to fight AIDS, TB and Malaria.

Read the complete story at:
http://timesofindia.indiatimes.com/cms.dll/html/uncomp/artcleshow?msid=244593

Web Call: A visit to Second Stop TB Partners' Forum, New Delhi website

http://www.stoptb.org/forum2003/index.html

The website hosted by the Government of India and dedicated to the 2nd Stop TB Partners Forum, which will be held on 4-5 December 2003 in New Delhi provides an interesting insight into the issues and the backdrop against which the convention will be held. The Forum proposes to assemble high-level delegations of the 22 highest tuberculosis burden countries, as well as special invitees from the G-8 countries, and all Stop TB partners. The progress at country level since the last meeting in 2001-and the significance of private and civil sector involvement are proposed to be the major items on the agenda. The website links to various pages which provide information on the Forum.
Agreement on the way forward to reaching the global TB targets in the form of the "New Delhi Pledges" that include "formulating a response to 2nd Ad hoc Committee ("The Hague Paper"), secure pledges of high-level political commitment and operational support from Partners to plans of the top High Burden Countries (HBC) and Reinforcing commitment and new partnership with private sector/civil society", are some of the objectives envisaged and presented on the "Objectives and Outcomes" age. The link to "Documents" has a report on the highlights of the first meeting of the forum; the other documents listed are still under development. The presentations to me made at the meeting are proposed to be available from this link. The need for fulfilling funding commitments for the Global Plan to Stop TB and to stress the need for renewing the commitment to the Stop TB pledges "now more than ever" are highlighted on the communications page. This is a good site to visit if you plan on attending the Forum or wish to follow the activities which will form an integral part of this vital meeting.