Editorial: Volume 18 Number 5.

India started the National TB Control Programme (NTCP) in 1962, based on a District TB Centre Model. A review of the NTCP, after nearly three decades of implementation, demonstrated that it had failed to make any significant epidemiological impact. The review, conducted by the Government of India (GoI) and the Swedish International Development Agency (SIDA) in 1992 concluded that the NTCP suffered from managerial weaknesses, inadequate funding, over-reliance on X-ray for diagnosis, non-standard treatment regimens, low rates of treatment completion, and lack of systematic information on treatment outcomes. The programme review also showed that only 30% of patients were diagnosed and, of these, only 30% were successfully treated. Based on the findings and recommendations of the 1992 review, the GoI evolved a revised strategy and launched the Revised National TB Control Programme (RNTCP) in the country based on the internationally recommended DOTS strategy.
  From October 1993 to 1996, the RNTCP was pilot-tested in a population of nearly 20 million. Following the successful pilot implementation of the programme, which demonstrated both technical and operational feasibility, a credit agreement was signed with the World Bank in 1996 to expand the programme in a phased manner. Support from other international agencies such as the Department for International Development (DFID) of the United Kingdom, Danish International Development Agency (DANIDA), Global Fund for AIDS, TB and Malaria (GFATM), United States Agency for International Development (USAID) and Global Drug Facility (GDF) helped to expand and achieve universal coverage.
  A rapid scale-up of the programme began in late 1998, when another 100 million population was covered under the RNTCP. In the past few years, the RNTCP has been expanding rapidly. By the end of September 2005, over 1059 million people (95% of the population) in more than 604 districts/reporting units were covered under the programme and complete nationwide coverage is expected by the end of 2005.
Gains and future road map of the programme
  Over the past 8 years, the RNTCP has made rapid gains and, since 1999, progress in global TB control has been determined by India’s success, which is expected to continue over the coming years. Over 4.8 million patients have been put on treatment under the RNTCP. Treatment success rates have more than tripled from 26% in the earlier programme to 86% under the RNTCP. Death rates have decreased from 29% to 4%, thereby saving over 800 000 additional lives since the inception of the programme.
  Over 600 District TB centres, nearly 11 000 microscopy centres and 2150 Tuberculosis Units have been upgraded. The programme has made provisions for contractual staff to ensure effective programme implementation and monitoring. The establishment of a sub-district level ‘Tuberculosis Unit’ covering a population of 500 000 with provision for a dedicated contractual Senior Treatment Supervisor and Senior Tuberculosis Laboratory Supervisor has strengthened the programme at the field level. These provisions will be continued in the next phase of the programme to consolidate the gains achieved so far by the RNTCP.
  The quality of diagnosis of TB patients under the RNTCP has improved by giving the highest priority to the provision of quality assured sputum smear microscopy services with RNTCP-designated microscopy centres serving populations of 100 000. One of the unique innovations under the RNTCP has been the development of ‘patient-wise boxes’, which contain the full course of treatment for one individual patient, ensuring that the treatment of that patient cannot be interrupted due to a lack of drugs. The RNTCP has effectively decentralized supervision via the sub-district TB Units, with inbuilt systems for monitoring and evaluation.
  The quality of diagnostic and treatment services is of utmost priority under the programme. A quality assurance protocol was initiated towards the end of phase I of the RNTCP and will be further strengthened in the coming phase by building the capacity of state-level laboratories to the level of an accredited RNTCP Intermediate Reference Laboratory (IRL), capable of implementing quality assurance protocol, and also perform quality assured culture and drug sensitivity testing (DST). A new strategy document for Supervision and Monitoring has laid down detailed guidelines, checklists and indicators for monitoring the programme at the Peripheral Health Institution (PHI)/ Designated Microcopy Centre (DMC), TB Unit, District, State and National level. The quality of DOTS implementation is already being monitored through select indicators collected routinely.
  The RNTCP has been successful in mobilizing political and administrative commitment to ensure adequate funds, staff and other key inputs, and in encouraging community participation at the grassroots level. The RNTCP has forged participation with other stakeholders, such as NGOs, private practitioners, medical colleges and other ministries’ health facilities (Employees’ State Insurance [ESI], Railways, Ports and Mines, Army, etc.), and the corporate sector. Over 1600 NGOs, 9000 private practitioners and 100 corporate houses are now involved in the programme. Guidelines for the management of hospitalized TB patients have been developed, and over 200 medical colleges have been involved. Medical colleges have made an important contribution to case detection, 10%–15% in some areas. With the establishment of a task force mechanism for the involvement of medical colleges in the RNTCP and 5 zonal nodal medical college centres, there is an increased professional consensus, although still not universal, between public health and medical opinion leaders on the appropriateness and feasibility of the RNTCP for TB control in India. These partnerships are constantly being reviewed to strengthen collaboration.
  The RNTCP is a human resource-intensive programme. Human resource development being the core for any successful programme, the programme has developed standardized modular training material for all levels of health staff. To date, over 420 000 personnel have been trained. To build the capacity of the states, the State TB Training and Demonstration Centres (STDCs), one in each of the large states, have been strengthened. These centres have a training unit, supervision and monitoring unit, and a laboratory unit.
  A systematic programme evaluation mechanism is in place, with the responsibility of planning and implementation of such evaluations decentralized to the state level. In 2004, internal evaluations were planned and conducted in 47 selected districts to evaluate the actual status of the RNTCP, including both the negative and the positive aspects of programme implementation. Based on the observations and recom-mendations of such evaluations, the programme has taken steps to rectify any problems identified, so as to continuously improve the performance of the RNTCP. These are supplemented by Centrally-driven district-level evaluations, regular programme review in the states by representatives from the Centre and district reviews by state and district officials.
  Under a joint National AIDS Control Programme (NACP)/RNTCP Action Plan, since 2001, collaborative TB/HIV control activities and coordination have been implemented by the RNTCP and the NACP. As a result, coordination and service linkages have been established between 242 voluntary counselling and testing centres (VCTCs) and RNTCP diagnostic and treatment centres in the 6 high-prevalence states of Andhra Pradesh, Karnataka, Maharashtra, Manipur, Nagaland and Tamil Nadu.
  TB/HIV activities are being scaled-up in 8 more states. HIV seroprevalence surveys among TB patients are under way in selected sentinel sites (4 districts) of Andhra Pradesh, Karnataka, Maharashtra and Tamil Nadu.
The RNTCP with the Indian Academy of Pediatrics has developed guidelines for the management of paediatric cases. During phase II, it is planned to procure and supply paediatric drugs in patient-wise boxes based on specific weight bands. Currently, nearly 6% of new cases registered under the programme are in the paediatric age group.
  Today, with the greatly expanded efforts to strengthen TB prevention and control programmes worldwide, there is growing concern about the reported and potential future rates of multidrug-resistant (MDR) TB (resistance to at least isoniazid and rifampicin). Though the prevalence of MDR-TB in India is under 3% in new cases, when translated into numbers, these cannot be ignored. The RNTCP views the treatment of MDR-TB patients as a ‘standard of care’ issue. However, recognizing that the treatment of MDR-TB cases is very complex, an RNTCP standardized second-line drug regimen has been developed following the internationally recommended DOTS Plus guidelines and will be provided from designated RNTCP DOTS Plus sites. In the initial years, these sites will be located in a limited number of highly specialized centres, at least one in each large state, and will have ready access to a state-level accredited culture and DST laboratory, the IRL, under the RNTCP. By 2010, these sites would be capable of registering 5000 patients every year.