India introduced the Revised National Tuberculosis Control Programme (RNTCP) in the mid 1990s, based on the World Health Organisation’s DOTS strategy. Researchers from New Delhi’s Lala Ram Sarup Institute and the London School of Hygiene and Tropical Medicine report on operational research at two pilot sites for the programme in New Delhi.

The objective of the new strategy is improved diagnosis and treatment supported by political commitment, regular drug supply and rigorous monitoring of treatment outcomes. The target is 85 per cent cure and 70 per cent coverage. RNTCP is now being extended in a phased manner to 102 districts covering a population of 271.2 million. Principles include:

• decentralised diagnostic and treatment networks integrated into primary healthcare
• sound programme management based on accountability and supervision of healthcare workers
• in-built evaluation of treatment outcomes
• directly observed treatment, in which a trained health worker supervises the swallowing of drugs.

The research involved semi-structured interviews with 59 DOT centre patients who were not on the RNTCP and interviews with 21 TB health visitors, plus non-participant observation. The reported ‘success rate’ for both clinics was greater than 80 per cent. However, they are clearly operating parallel treatment systems. Health workers screen patients to determine their ability to conform to the direct observation of treatment. One clinic had 489 patients on DOT and 842 (63 per cent) on unsupervised treatment. The other had 409 on DOT and 422 (51 per cent) on unsupervised treatment.

Patient characteristics identified by health workers as hampering completion of treatment include:

• social marginalisation
• low level of integration in the city
• absolute poverty
• past history of irregular treatment
• itinerant labouring or work requiring travel.

So RNTCP excludes the most vulnerable from the best available care, demonstrating the potential dangers of target-driven programmes. This is a coping strategy by staff, working towards a project or programme goals rather than from a TB control orientation. However, the researchers suggest that the very same methods currently used to exclude vulnerable patients could help to identify those most in need of extra care and support. They also propose more extensive or flexible hours of operation and neighbourhood-based DOT to meet unmet demand in the community.

Source(s):
‘TB control, poverty and vulnerability in Delhi, India’, Tropical Medicine and International Health 7(8): 693-700, by V. Singh et al., 2002
HINARI subscribers can access the full-text article here. Full document.

Funded by: UK Department for International Development

id21 Research Highlight: 5 February 2003

Further Information:
John Porter
London School of Hygiene and Tropical Medicine
Keppel Street
London
WC1E 7HT
UK

Contact the contributor: John.Porter@lshtm.ac.uk

London School of Hygiene and Tropical Medicine, UK

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