Revised National Tuberculosis Control Programme TRIBAL ACTION PLAN

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1 Public Disclosure Authorized Public Disclosure Authorized Public Disclosure Authorized Public Disclosure Authorized Revised National Tuberculosis Control Programme TRIBAL ACTION PLAN July 2012 Central TB Division, Directorate General of Health Services, Ministry of Health & Family Welfare, Nirman Bhavan, New Delhi

2 Introduction The term 'Scheduled Tribes' first appeared in the Constitution of India. Article 366 (25) defined scheduled tribes as "such tribes or tribal communities or parts of or groups within such tribes or tribal communities as are deemed under Article 342 to be Scheduled Tribes for the purposes of this constitution". Article 342, prescribes procedure to be followed in the matter of specification of scheduled tribes. According to the 2001 census, about 8.10 percent of India s total populations tribal. The Constitution of India incorporates several special provisions for the promotion of educational and economic interest of Scheduled Tribes and their protection from social injustice and all forms of exploitation. These objectives are sought to be achieved through a strategy known as the Tribal Sub-Plan strategy, which was adopted at the beginning of the Fifth Five Year Plan. GOI has developed The Tribal Sub Plan strategy in 1972 under the Chairmanship of Prof S.C. Dube for the rapid socio-economic development of tribal people and was adopted for the first time in the Fifth Five Year Plan. The strategy adopted continues till this day. The TSP strategy has been in operation in 22 States and 2 UTs. The states where Tribal population is more than 60% of the total Population of State in those states Annual Plan is itself a Tribal Plan Tribal Population and RNTCP Tribal communities continue to face multiple challenges including in accessing TB diagnostic and treatment services despite the implementation of the Tribal Action Plan in May 2005 under Phase II E. A study based on an analysis of NFHS 2 data reported that TB prevalence was greatest among the scheduled tribe women (2.63 %). Living conditions also had a bearing on the prevalence of the disease. Factors such as living in kutcha houses and use of smoke-causing fuel for cooking were linked significantly to the prevalence of TB. The RNTCP has prioritized special populations and hard to reach groups in both the earlier phases (I and II). Groups that were specifically identified included tribal populations for whom a specific Tribal Action Plan was developed with clear guidelines and interventions for tribal communities. The programme has sustained focus to provide effective and quality services for the tribal population; it has made several special norms and guidelines for better implementation in the tribal areas which includes more incentives, human resources and decreased population size for designated microscopy centres when compared to the norms for plain areas. The existing RNTCP Tribal Action Plan has the following objectives: 1. Encourage tribal populations to report early in the course of illness for diagnosis. 2. Enhance treatment outcomes amongst tribal populations 3. Promote closer supervision of tribal areas by RNTCP state Apart from that Program has also set certain targets for the tribal areas: Increasing trends of case detection and treatment success in a sample of predefined districts with higher proportion of tribal population Treatment success and default rates of female patients compared to male patients Locally adapted IEC messages and patient education material in place Operational research study results available to assist in further planning and implementation of RNTCP in tribal pockets

3 The tribal action plan is also a step towards providing special assistance, including some financial support, in the hard and difficult tribal areas. New interventions and strategies that specifically address these themes and issues were devised and implemented within the programme. Achievements of TAP under RNTCP: The Tribal Action plan under RNTCP was implemented in 85 districts across 21States and UTS of country. List of the states and districts is in Annex 1. The annual results have shown that the case detection and treatment rate among new smear positive case in tribal districts is higher than the national results. The treatment success rate is 88%. 45,053 (58%) of total cases registered in tribal districts are reported by tribal community volunteers. Background of Revised Tribal Action Plan 2012 The aim of RNTCP in is Universal Access to quality diagnosis and treatment for all Tuberculosis (TB) patients in the community. Program will give more attention to special population group which includes tribal population also. In 2011 RNTCP did Social Assessment Study with following objectives: 1. To study the changing scenario of health provision, the health seeking behaviour of the marginalized and vulnerable groups, and the socio-cultural context in which the next phase of RNTCP is to be implemented. 2. To identify the barriers and facilitating factors associated with full utilization of services by marginalized and vulnerable groups; in terms of accessibility, acceptability and affordability, both for diagnosis and treatment under RNTCP. 3. To recommend strategies for improving programme protocol and strengthening the programme interventions to ensure provision of services to the certain groups. The study focussed on the tribal and urban slum populations from among the marginalized and vulnerable groups. The major findings of this study specific to the tribal population are following: General health seeking behaviour Would seek treatment in case of illness Choice of service provider varies Knowledge and perception about TB Poor awareness that cough more than two weeks could be TB Heard of TB, main sources TV/radio/hoardings/doctor Aware of spread, predisposing factors and symptoms Not aware of cause of TB Most had disclosed illness to family and friends (however TB suspects were fearful of discrimination and social isolation) TB treatment and care

4 Long pathway to accessing care (home/traditional remedies self-medication/ medication from pharmacies ---- informal providers ---- private providers ---- government health facility) Time lag between start of symptoms and treatment initiation ranges from 14 days to 4 months (RNTCP cases); 7 45 days (non-rntcp cases) Preference for - a. government centres - free drugs/low cost of treatment, no difficulty in obtaining drugs b. private providers easier access, quicker services so no loss of daily wages, general trust, overall dissatisfaction with government facilities Reasons for not availing of RNTCP facilities (non-rntcp cases) - delay in initiation of treatment, too many tablets, side effects, cost of additional therapy, improper attitude of health staff Cost of treatment RNTCP cases free but additional cost for transport (sizeable expense), supplementary drugs, good food Non-RNTCP cases physician consultation, cost of diagnostic tests and medicines, transport; ranged from Rs. 3,000 Rs. 70,000 Reason for default Side effects of drugs Improvement of symptoms Stay away from home Awareness of RNTCP Majority never heard about RNTCP/DOTS Based on these Findings it has given certain recommendations: Community level awareness programmes so that patients go directly to health centre and not depend on informal providers DOTS medicines at doorstep to avoid transport cost Medicines of less strength to reduce side effects will help patients to continue normal work Free medicines under programme to be made available for those taking private treatment Improve government health services mainly staff attitude and environment in which services are provided Revised Tribal Action Plan 2012 The revised TAP is based on the recommendations of this study in addition to the special focus strategies planned for Tribal districts. Some of these strategies are new while many of them are continued from the previous plan: Existing Strategies that will continue: Engaging contractual staff from community: The RNTCP will increasingly recruit contractual staff from the tribal communities in districts with large tribal populations.this staff will be trained and empowered to function adequately through NGO support where necessary.

5 Filling up of staff vacancies: The RNTCP will fill staff vacancies in these districts on priority, funding it from resources available for contractual appointments. These districts will also be encouraged to identify volunteers from the tribal communities to support patients on treatment. Programme support will be provided to actively implement the Tribal Action Plan already developed in Phase II and with regular monitoring. Development of locally relevant IEC: Priority will be accorded to the development of cultural and context specific IEC materials by engaging the local population in their development. Allowance of enhanced norms: Financial norms and programme support will be reviewed and enhanced to empower and engage special populations in the poor and backward districts. Appropriate incentives will be considered to increase access to diagnosis and complete treatment services. New Strategies Transport mechanisms: Sputum transport will be encouraged through NGO collaborative schemes and patients / attendants will be provided travel support where necessary. Increased involvement of civil society: Civil society and NGOs will be progressively involved to expand the reach of the RNTCP in these districts. Lessons learned from the ongoing Global Fund Round 9 grant will be extended to all districts in the country in a phased manner so that access of special populations to TB services is increased. NGO schemes will be reviewed to incorporate additional needs of special population groups during the plan period. Making DOT more patient friendly While DOT remains at the heart of the strategy and efforts would be made to make it more convenient, several other measures are envisaged to improve treatment adherence and reduce default rates. Decentralization of DOT services: In order to make DOT convenient by place and time for the patients, it is necessary that DOT be provided by somebody who is as close to the patient s residence/workplace as possible. The patient will not need to pay to reach the DOT centre. This requires strengthening and expanding the network of DOT providers in the community by including self-help groups, mahila mandals, ASHAs, anganwadi workers, religious leaders, opinion makers, cured TB patients, NGOs and private providers etc. Flexible strategies like workplace DOT would be proactively explored, wherever feasible. However this move to decentralize DOT services will be balanced by the need to maintain accountability of the DOT providers to the health services, and continued need for supervision of the involved DOT providers by the STS. The programme will ensure continued supervision and monitoring of DOT services by the STS, and STS assistance to DOT providers in retrieval of patients who are late for treatment. Choosing the right DOT provider: DOT works well when, there is a human connect between the provider and the patient. The option to choose the DOT provider may be provided to the patient. Experience has shown that there is no single category of providers who are the best DOT providers for all patients; but for each patient, there is a DOT provider who is the best choice. It is the responsibilities of the Medical officer of the PHI to enable the patient make this choice.

6 To Make DOT flexible: During treatment course, many patients face exigencies in their personal lives which may need them to move out of station and unable to visit the DOT provider on those days. In such circumstances, provision will be made to provide extra drugs required for self-administration while documenting the same on the treatment cards. The empty blister will be collected back from the patient on his/her return and would be used to assess compliance. Encouraging the community DOT: In order to encourage the community DOT, the honorarium would be enhanced to motivate and incentivize the providers to ensure that they follow-up the patients diligently and ensure cure. It is proposed to increase the honorarium to community DOT providers at the rate of Rs 1000, Rs 1500 and Rs 5000 for every new, retreatment and MDR-TB patient who completes treatment respectively with disbursements split at completion of Intensive and continuation phase. Travel support for HIV-infected TB patients to reach ART centre: In order to improve the linkage of HIV-infected TB patients to ART centre by addressing access barriers, it is proposed that travel support be provided to the patients to enable them to reach the ART centre. Incentivizing the patients to complete treatment: RNTCP currently provides incentives to patients in tribal areas, to encourage them to come regularly to health facility for follow-ups and complete treatment. It has been proposed to enhance and extend this incentive at a rate of Rs per patient to be disbursed on completion of treatment. This would be piloted in select areas for assessing feasibility and effectiveness before nationwide scale-up. Extending RNTCP services to patients treated in private sector in tribal districts atfree of cost.

7 Annex 1 List of Tribal District State District State District Andaman & Nicobar Andaman & Nicobar Islands * Islands * Manipur Senapati * Andhra Pradesh Adilabad * Manipur Tamenglong * Arunachal Pradesh East Kameng * Manipur Ukhrul * Arunachal Pradesh East Siang * Meghalaya East Garo Hills * Arunachal Pradesh Lower Subansiri * Meghalaya East Khasi Hills * Arunachal Pradesh Papum Pare * Meghalaya Jaintia Hills * Arunachal Pradesh Tawang * Meghalaya Ri Bhoi * Arunachal Pradesh Tirap Meghalaya South Garo Hills * Arunachal Pradesh Upper Siang * Meghalaya West Garo Hills * Arunachal Pradesh Upper Subansiri * Meghalaya West Khasi Hills * Arunachal Pradesh West Kameng * Mizoram Aizawl * Arunachal Pradesh West Siang * Mizoram Champhai * Assam Karbi Anglong * Mizoram Kolasib * Assam North Cachar Hills * Mizoram Lawngtlai * Chhattisgarh Bastar * Mizoram Lunglei * Chhattisgarh Dantewada * Mizoram Mamit * Chhattisgarh Jashpur * Mizoram Saiha * Chhattisgarh Kanker * Mizoram Serchhip * Chhattisgarh Surguja Nagaland Dimapur * D & N Haveli Dadra & Nagar Haveli Nagaland Kiphire * Gujarat Dahod * Nagaland Kohima * Gujarat The Dangs * Nagaland Longleng* Gujarat Valsad * Nagaland Mokokchung * Himachal Pradesh Kinnaur * Nagaland Mon * Himachal Pradesh Lahul & Spiti * Nagaland Peren * Jammu & Kashmir Kargil * Nagaland Phek * Jammu & Kashmir Leh (Ladakh) * Nagaland Tuensang * Jharkhand Gumla Nagaland Wokha * Jharkhand Khunti Nagaland Zunheboto * Jharkhand Lohardaga * Orissa Gajapati Jharkhand Pashchimi Singhbhum * Orissa Kandhamal Jharkhand Purbi Singhbhum Orissa Koraput Jharkhand Ranchi Orissa Malkangiri * Lakshadweep Lakshadweep * Orissa Mayurbhanj Madhya Pradesh Alirajpur Orissa Nabarangapur Madhya Pradesh Barwani Orissa Nuapada Madhya Pradesh Dhar Orissa Rayagada Madhya Pradesh Dindori Orissa Sundargarh Madhya Pradesh Jhabua Rajasthan Banswara Madhya Pradesh Mandla Rajasthan Dungarpur Maharashtra Nandurbar * Sikkim North Sikkim * Manipur Chandel * Tripura Dhalai * Manipur Churachandpur *

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