Country experience on engaging large hospitals - INDIA

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1 Ninth Meeting of the Sub- group on PPM for TB Care and Control and Global Workshop on Engaging Large Hospitals, August 2013 Country experience on engaging large hospitals - INDIA Sreenivas A Nair WHO Country Office for India 1

2 Will discuss: The Challenge WHO-RNTCP TB PPM model- Involving Medical Colleges Formation Structure Monitoring Results Success factors, challenges and opportunities 2

3 Tuberculosis in India and scope of PPM Other countries 18% India 25% Phillipines 3% Other 13 HBCs 18% Pakistan 5% Ethiopia 3% Bangladesh 4% Nigeria South Africa 2% 6% Indonesia 5% China 11% TB notification in India (2-2.5) 1.3 Missing nearly a million incident cases!

4 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

5 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.

6 Structure of Task forces National Task Force CTD 7 Medical Colleges NTI NIRT NITRD WHO STO of each State Zonal Task Force 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

7 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

8 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

9 Patients from RNTCP District Medical Colleges TB Suspect Outdoor patient OPD DOTS Directory District/State/National Paper/Electronic Stay in Medical College DOTS Centre Drugs OPD OPD OPD OPD Diagnosed as TB Internal referral to DOTS Centre in Medical College / Referral Register Outside Feedback Referral Form in triplicate (pre-paid) form with patient, 1 sent to DTO and 1 sent to TU

10 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

11 Monitoring Referral Register Referral for treatment form Feedback Monthly and Quarterly Reports

12 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 P / EP Diagnosis Type of patient (N / R / F / TAD / O 3 ) CAT I / II / III Health facility to which patient has been referred Feedback 4

13 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 Disease Classification Pulmonary Extra-pulmonary Site Category of Treatment Category I Category II Category III Type of Patient New Relapse Failure Treatment after default Other (specify) Sputum Status Date Month Year Result Laboratory number Name of Laboratory Relevant examination for Smear negative / Extra pulmonary cases Remarks Signature Date referred Designation Form A For use by the health facility where the patient has been referred Name of patient Age Sex M F Date of referral Serial Number 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.)

14 Reporting system for Medical Colleges Central TB Division National Task Force Zonal quarterly report ( within 30 days) State quarterly report (within 20 days) Zonal Task Force State TB Cell State Task Force District TB centre Quarterly report (within 7 days) TB Unit Monthly PHI report (within 5 days) Medical College -1 Medical College -2

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

16 Trend of case notification from medical colleges s+ diagnosed new smear positive TB-mc Total TB notified from Medcal colleges 16

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

18 Proportion of TB cases notified by medical colleges over the years by type of cases % 37% 35% 31% 21% 13% 13% 13% 14% 13% 14% 12% 14% 14% 7% Proportion from Med colleges-nsp Proportion from Med colleges-nsn Proportion from Med colleges-ep 18

19 Summary of contribution by different health sectors in 14 intensified urban PPM sites % 90% 80% 70% 60% NGOs NGOs NGOs Pvt. Practitioners Pvt. Practitioners Pvt. Practitioners Medical College Other Govt. Medical College Other Govt. Medical College Other Govt. NGOs Pvt. Practitioners Medical College Other Govt. Corp. Sector NGOs 50% 40% 30% 20% State Govt. State Govt. State Govt. State Govt. Pvt. Practitioners Corp. Sector Medical College Other Govt. State Govt. 10% 0% Contribution to referral of chest symptomatics Contribution to all smear positive diagnosis Contribution to new smear positive case detection Contribution to DOT provision

20 Number of MDR TB Cases put on treatment Population covered under PMDT services (in millions) Population in Millions PMDT services-role of Medical Colleges ## Laboratories Certified under RNTCP Cumulative data up to March 2013 MDR TB Suspects Tested MDR TB case initiated on Rx XDR TB cases initiated on Rx MDR TB Cases put on treatment 0 3Q-07 4Q-07 1Q-08 2Q-08 3Q-08 4Q-08 1Q-09 2Q-09 3Q-09 4Q-09 1Q-10 2Q-10 3Q-10 4Q-10 1Q-11 2Q-11 3Q-11 4Q-11 1Q-12 2Q-12 3Q-12 4Q-12 1Q-13 Quarter 0

21 PMDT and Medical Colleges Laboratory services PMDT sites (64/89) Generation of evidence 21

22 Success factors 22

23 Success factors 23

24 Success factors 24

25 Success factors 25

26 Challenges 26

27 Challenges 27

28 Challenges 28

29 Challenges 29

30 Opportunities 30

31

32 Opportunities 32

33

34 India PPM on the move National Strategic Plan 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

35 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

36 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

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