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JMM Book Final SEA-TB-348 Distribution: Limited Ministry of Health & Family Welfare Government of India Joint Monitoring Mission Revised National Tuberculosis Control Programme (RNTCP), India 21 – 31 August 2012 SEA-TB-348 Distribution: Limited Ministry of Health & Family Welfare Government of India Joint Monitoring Mission Revised National Tuberculosis Control Programme (RNTCP), India 21 – 31 August 2012 Writing group (in alphabetical order): A Sreenivas, Fraser Wares, Guy Stallworthy, Haileyesus Getahun, Jeremiah Muhwa Chakaya, Kenneth G Castro, Madhukar Pai, MVA Kumar, Nalini Krishnan, Patrick Moonan, Patrick Mullen, Peter Small, Puneet Dewan, Rebecca Furth, Rupak Singla, Suvanand Sahu, Varinder Singh © World Health Organization 2013 This document is not issued for the general public, and all rights are reserved by the World Health Organization (WHO). The document may not be reviewed, abstracted, quoted, reproduced or translated, in part or in whole, without the prior written permission of WHO. No part of this document may be stored in a retrieval system or transmitted in any form or by any means – electronic, mechanical or other – without the prior written permission of WHO. The views expressed in this document, by the aforementioned authors, are solely the responsibility of those authors. Preface I am pleased to introduce the Report of the 2012 Joint Monitoring Mission (JMM). The Report has made far-reaching recommendations and suggestions; it also provides an action blueprint for TB control efforts in the country. At the request of the Government of India (GOI), the WHO Country Office for India, along with the technical, developmental and implementing partners of the Revised National Tuberculosis Control Programme, has been organizing a JMM every three years to coordinate and guide policies and planning for more effective TB control efforts. The 2012 JMM came at an opportune moment as it has been able to provide inputs on strategic approaches and innovative mechanisms for achieving the key targets of the 12th Five Year Plan. It has reviewed the progress, challenges and plans for India's TB control initiatives and programmes, and advised the GoI and its partners on the path to be followed for achieving universal access to TB care. It has also reviewed and endorsed the ambitious National Strategic Plan (NSP) for TB Control (2012-2017). Some of the key recommendations of JMM include: engaging all care providers to achieve universal access to TB care and prevent drug resistance; extending case- finding activities and deploying improved diagnostics and diagnostic strategies; and strengthening health systems. The JMM has appreciated the government's TB control programme. However, it has cautioned that further successful implementation requires an urgent and emphatic expansion in the prioritization, development, financing and deployment of innovative activities to rapidly detect and correctly treat TB cases, irrespective of public or private sector provision of care. We strongly urge the government and all the partners to take on board the suggestions of the JMM and accord priority to areas that need to be strengthened. Looking ahead, the roadmap must include: greater urgency and stronger efforts to prevent and address TB; recognition that both, controlling drug sensitive TB and drug resistant TB cannot be done through the public sector alone; the need to turn off the tap of generation of new drug-resistance; thinking innovatively and committing to working with both, the formal and non-formal private sector; accepting that prevention alone is insufficient and must in parallel put in place systems for diagnosis and treatment; and recognizing that partnerships are crucial for success because no one can do it alone. We welcome and applaud the leadership for investing more in health. As the country becomes an economic superpower, developmental assistance will come less to India, and increasingly come from India. In TB, India has taught the world how to structure a basic control programme, how to prepare a patient-wise box, and how to organize and deliver programme services at scale. There is no doubt in my mind that India can and will continue to be the leader in TB control globally. Dr Nata Menabde WHO Representative to India K. Desiraju GOVERNMENT OF INDIA Secretary MINISTRY OF HEALTH & Department of Health & FW, FAMILY WELFARE, Tel: 23061863 Fax: 23061252 NIRMAN BHAVAN, e-mail: secyhfw@@nic.in NEW DELHI. 110108 FOREWORD The Revised National TB Control Programme (RNTCP) has entered the 16th year of its implementation in the country. While the programme has been extremely successful, new challenges requiring our urgent attention have also emerged over the years. The Joint Monitoring Mission (JMM) was conducted with clearly defined objectives of 'reviewing the country's progress towards the TB-related Millennium Development Goals (MDGs), challenges and plans for TB control efforts, and to advise Government of India and partners on the pathway towards achieving Universal Access to TB care'. The JMM also provided inputs on strategic approaches and innovative mechanisms for achieving the key targets of the 12th Five Year Plan. The JMM has comprehensively drafted their recommendations presented through this report. It is in this context that we take note of the report of the 5th Joint Monitoring Mission (JMM) undertaken in August 2012 by WHO Country Office for India along with a number of other stakeholders and partners. The Government of India is committed towards the long term vision of TB free India. We must provide for quick and accessible means of quality diagnosis and treatment. The ambit of RNTCP must be expanded to cover or provide for the patients currently being treated outside the programme. Adherence to full and complete treatment needs to be emphasized. We must gear up for the larger case detection of drug resistant TB expected with the rapid expansion of programmatic management of drug resistant TB in India undertaken in the last few years. We trust that the TB programme managers, both in the Central and State governments, along with all the other stakeholders will carefully study the findings and recommendations of the JMM and make sure fresh approaches are brought for the new and emerging challenges. (Keshav Desiraju) Contents Abbreviations and acronyms iii Executive summary (including main recommendations) 1 Introduction 6 1. Case detection 10 2. Diagnosis 16 3. TB treatment 23 4. Programmatic management of 30 drug-resistant TB (PMDT) 5. TB-HIV 39 6. Paediatric tuberculosis 43 7. Engaging private providers and public–private partnerships 51 8. Surveillance, monitoring, evaluation 59 and impact measurement 9. Human resource development 64 10. Advocacy, communication and social mobilization 70 11. Programme financing and integration with health systems 77 12. Research to improve TB care and control 86 13. Technical support 90 Annexes 95 Annex 1 - List of participants 95 Annex 2 - List of team members for field visits 101 Annex 3 - State reports Summaries of findings and recommendations: 105 Bihar 105 Karnataka 115 Maharashtra 122 Punjab 131 Uttar Pradesh 140 West Bengal 147 Abbreviations and acronyms ACSM advocacy, communication and social mobilization AIC airborne infection control ANM auxiliary nurse midwife ART antiretroviral therapy ASHA Accredited Social Health Activist C/DST culture and drug susceptibility testing CBCI-CARD Catholic Bishops' Conference of India–Coalition for AIDS and Related Diseases CBNAAT cartridge-based nucleic acid amplification test CBO community-based organization CCT conditional cash transfer CDR case detection rate CLHIV children living with HIV/AIDS CPT co-trimoxazole preventive therapy CSO civil society organization CTD Central Tuberculosis Division DALY disability-adjusted life year DCGI Drugs Controller General of India DFID Department for International Development DMC designated microscopy centre DOT directly observed treatment DOTS directly observed treatment, short-course DRS drug resistance surveillance DR-TB drug-resistant TB DST drug susceptibility testing DTO district TB officer DTU district tuberculosis unit EQA external quality assurance FAQs frequently asked questions FDC fixed-dose combination FIND Foundation for Innovative Diagnostics FLD first-line drug FM fluorescent microscopy GDF Global TB Drug Facility ii GF Global Fund GoI Government of India HRD human resource development IAP Indian Academy of Paediatrics ICDS Integrated Child Development Services ICT information and communications technology ICTC integrated counselling and testing centre IEC information, education and communication IGRA interferon-gamma release assay IMA Indian Medical Association IMNCI Integrated Management of Neonatal and Childhood Illness INH isoniazid IPC interpersonal communication IPT isoniazid preventive therapy IRL intermediate reference laboratory JALMA National JALMA Institute of Leprosy and other Myobacterial Diseases JMM Joint Monitoring Mission KAP knowledge, attitude and practice LED-FM light-emitting diode-based fluorescence microscopy LIMS laboratory information management system LPA line probe assay LRS Lala Ram Sarup Institute of Tuberculosis and Respiratory Diseases MCH maternal and child health MCI Medical Council of India MDG Millennium Development Goal MDR multidrug resistance MO medical officer MoHFW Ministry of Health & Family Welfare MPW multipurpose worker NACO National AIDS Control Organization NACP National AIDS Control Programme NCDC National Centre for Disease Control NEP new
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