1

Ninth Meeting of the Sub- group on PPM for TB Care and Control and Global Workshop on Engaging Large Hospitals, 28-30 August 2013 Country experience on engaging large hospitals - INDIA

Sreenivas A Nair WHO Country Office for India

Will discuss: • The Challenge

• WHO-RNTCP TB PPM model- Involving Medical Colleges

Formation

Structure

Monitoring

Results

Success factors, challenges and opportunities

2

Tuberculosis in India and scope of PPM

Indonesia5%

Nigeria2%

Other countries18%

Other 13 HBCs18%

China11%

South Africa6%

Bangladesh4%

Ethiopia3%

Pakistan5%

Phillipines3%

India25%

TB notification in India 2012

Missing nearly a million incident cases!

2.2 (2-2.5)

1.3

Medical Colleges: Need for involvement

• Medical college faculty –Opinion leaders and trendsetters –Teachers imparting knowledge & skills – Role models for practicing physicians

• Large hospitals

–Out patient care –In patient care- specialty services

Involvement of medical colleges: milestones

•1997: National consensus conference on TB Control • 2001: National workshop of medical college professors

• 2002: Consensus workshops in states, medical colleges, Identification of seven nodal centers and Evolution of task force mechanism, processes & structure

• 2003: Annual national and zonal task force meetings State Task force meetings Operational research committees.

National Task Force

CTD 7 Medical Colleges NTI NIRT

Zonal Task Force

STO of each State State Task Force representative from each State (Med Col)

State Task Force - 2 tier in States with large number of Med Col

STO of the state Representative – 1 from each Medical College

Structure of Task forces

NITRD WHO

Steps for medical college involvement

• Form core committee

• Sensitization of faculty members

• Identify and train staff

• Appoint and train contractual staff as required and sanctioned (MO/ LT/ TBHV)

• Establish a DMC cum DOT centre

Roles and responsibilities • RNTCP provides support

for: – Commodity Assistance

Drugs Lab consumables Printed material Binocular microscopes

– Manpower support Contractual staff

– Training of staff – Civil works for laboratory,

PMDT site

• Expectations from medical colleges

– Diagnosis and treatment of TB including DR-TB For outdoor patients

For indoor cases

– Reporting requirements Monthly program management

report to RNTCP

Quarterly report to State Task Force

PMDT reports

Medical Colleges

Patients from RNTCP District

TB Suspect

OPD Diagnosed as TB

Internal referral to DOTS Centre in Medical College / Referral Register

DOTS Directory District/State/National Paper/Electronic

Stay in Medical College Outside DOTS Centre

Referral Form in triplicate (pre-paid)1

Drugs

Outdoor patient

OPD OPD OPD OPD

Feedback

1 1 form with patient, 1 sent to DTO and 1 sent to TU

In-door patients

Attending physician prescribes RNTCP regimen

All indoor patients who reside in an RNTCP district, to be treated with RNTCP regimens using prolongation pouches. The DOTS Centre of the Medical College must be informed of the patient’s admission as soon as possible. The patient will be registered under the local TU. The drug requirements to operationalise this system needs to be assessed by the respective DTOs and STOs, and CTD.

Via the DOTS Centre in the Medical College

On discharge, patient transferred to the DOTS centre nearest to the residence to continue and complete treatment

Monitoring

• Referral Register

• Referral for treatment form

• Feedback

• Monthly and Quarterly Reports

Referral Register

SN Date on which the patient

was referred

Name of the

patient

Age Sex Address of

patient 1

Date of smear examination,

Lab Serial Number and

results 2

Diagnosis Health facility to

which patient has

been referred

Feedback 4

P / EP

Type of patient (N / R / F / TAD / O 3)

CAT I / II /

III

Form A Serial Number REVISED NATIONAL TUBERCULOSIS CONTROL PROGRAMME Referral for Treatment Form (Fill in triplicate. Send one copy to the respective DTO receiving the patient [Form A], send one copy to the health facility where the patient is referred to [Form B], and give one copy to the patient [Form C]) Name and address of referring health facility__________________________________________________________________ Name of health facility to which patient is referred _____________________________________________________________

Name of patient _________________________________________________ Age _____________________ Sex M F Complete Address _______________________________________________________________________________________ _______________________________________________________________________________________

Category of Treatment Category I Category II Category III

Disease Classification Pulmonary Extra-pulmonary Site _______________

Sputum Status Date ______ Month ______Year_________ Result _______________________ Laboratory number ________________ Name of Laboratory ____________ Relevant examination for Smear negative / Extra pulmonary cases __________________ ___________________________________

Type of Patient New Relapse Failure Treatment after default Other (specify)_________________

Remarks ________________________________________________________________________________________________ ___________________________________________ Signature __________________________________________ Date referred ________________________________________ Designation ________________________________________ ------------------------------------------------------------------------------------------------------------------------------------------------------------------- Form A Serial Number For use by the health facility where the patient has been referred Name of patient _________________________________________________________________

Age___________________________ Sex M F Date of referral _____________________________ Name of receiving health facility _________________________ Name of TB Unit and District ______________________ The above-named reported at this health facility on___________ and has been put on treatment on _________________ Signature _____________________________ Designation ______________________ Date _____________ (Send this part back to the referring unit as soon as the patient has reported and has been initiated on RNTCP treatment.)

State TB Cell

Central TB Division

District TB centre

TB Unit

National Task Force

State Task Force

Zonal Task Force

Medical College -2

Medical College -1

Monthly PHI report (within 5 days)

Quarterly report (within 7 days)

State quarterly report (within 20 days)

Zonal quarterly report ( within 30 days)

Reporting system for Medical Colleges

15

276 286 307

321 343

262 273 282 291 315

2008 2009 2010 2011 2012

Medical College involvement in RNTCP number of med coleges number involved in RNTCP

16

0

50000

100000

150000

200000

250000

2008 2009 2010 2011 2012

Trend of case notification from medical colleges

s+ diagnosed new smear positive TB-mc Total TB notified from Medcal colleges

17

77966 79020 84015

87271 84697

28287

45666 49788 49031 45548 46540

71531

81615 83824 82067

2008 2009 2010 2011 2012

Trend notification by type of cases new smear positive TB-mc new smear negative TB-mc extra pulmonary TB-mc

18

13%

7%

21%

13% 12%

31%

13% 14%

35%

14% 14%

37%

13% 14%

35%

Proportion from Med colleges-NSP Proportion from Med colleges-NSN Proportion from Med colleges-EP

Proportion of TB cases notified by medical colleges over the years by type of cases

2008 2009 2010 2011 2012

Summary of contribution by different health sectors in 14 intensified urban PPM sites 2011

State Govt.State Govt. State Govt.

State Govt.

Other Govt.Other Govt.

Other Govt.

Other Govt.Medical College

Medical CollegeMedical College Medical College

Pvt. Practitioners Pvt. Practitioners Pvt. PractitionersPvt. Practitioners

NGOs NGOs NGOs NGOs

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Contribution to referral ofchest symptomatics

Contribution to all smearpositive diagnosis

Contribution to newsmear positive case

detection

Contribution to DOTprovision

NGOsPvt. PractitionersCorp. Sector Medical CollegeOther Govt.State Govt.

Corp. Sector

0

1000

2000

3000

4000

5000

6000

0

200

400

600

800

1000

1200

14003Q

-07

4Q-0

71Q

-08

2Q-0

83Q

-08

4Q-0

81Q

-09

2Q-0

93Q

-09

4Q-0

91Q

-10

2Q-1

03Q

-10

4Q-1

01Q

-11

2Q-1

13Q

-11

4Q-1

11Q

-12

2Q-1

23Q

-12

4Q-1

21Q

-13

MD

R T

B C

ases

put

on

trea

tmen

t

Popu

latio

n in

Mill

ions

Quarter

Number of MDR TB Cases put on treatment Population covered under PMDT services (in millions)

## Laboratories Certified under RNTCP

PMDT services-Role of Medical Colleges 4 4 5 7 8 9 13 13 18 18 18 19 19 20 27 29 31 34 37 38 42 45 47

Cumulative data up to March 2013

MDR TB Suspects Tested 182716 MDR TB case initiated on Rx 25727 XDR TB cases initiated on Rx 209

PMDT and Medical Colleges

21

• Laboratory services

• PMDT sites (64/89)

• Generation of evidence

22

Success factors

23

Success factors

24

Success factors

25

Success factors

Challenges

26

27

Challenges

28

Challenges

29

Challenges

Opportunities

30

32

Opportunities

India PPM – on the move

• National Strategic Plan 2012-17- Universal Access to TB Care- More thrust in PPM

– Establish PPM mechanisms

National

Technical working group (for guidance, policy advice)

Technical support unit (for help to States for contracting)

State

PPM cell (internal or contracted) to help States contract and monitor intermediary agencies; guided by national level TSU.

Private Provider Interface Agency (PPIA)– to manage the many points of contact, monitor, move micro-payments for services

Approaches • Accreditation/certification

• Innovative financing

• Diagnostics- labs

• Integrate with enhanced surveillance

• Schemes remain, but will be de-emphasized or phased out in favor of whatever works better

Private Public Interface Agency (PPIA)

• Improve case-finding, appropriate treatment and notification of cases

• Ensure notification of cases diagnosed & treated cases • Ensure minimum quality standards as per the ISTC • Provide or reimburse drugs for privately-treated patients for

regimens • Voucher/conditional cash transfer to patients (to use to

purchase drugs that meet govt quality standards) • And/or: social marketing of anti-TB drugs following agreed

procedures and quality standards • Design and deploy financing mechanisms to meet objectives