Monitoring & Evaluation of RNTCP

1 Monitoring & Evaluation of RNTCPDr Rajeswari RamachandranRetd. Dy. Director (Sr Gr) tuberculosis Research Centre (ICMR)ChennaiRevised national TB control Programme NTPinIndiasince1962 Internationalevaluationdonein1992 Programmerevisedin1993,adoptinginternati onallyacceptedDOTS strategy RNTCP launchedasanationalprogrammein1997&rapid expansionoftheprogrammestartedthereafter EntirecountrycoveredbyMarch2006 Objectives of RNTCP Toachieve&maintainacurerateofatleast85%a mongnewlydetectedsmear-positivepulmonary TBcases Toachieve&maintaindetectionofatleast70%o fsuchcasesinthepopulationFeatures of RNTCP Creation of sub-district unit for every 500,000 population (TU) Supervisory staff at Sub-district level Modular participatory training for the staff at all level Establishing microscopy center for every 100000 popn. (DMC) Establishment of QA system (sputum microscopy & drugs) TB register at the TU level Uniform recording & reporting system Decentralized service delivery with community participation Patient-wise drug boxes Regular Monitoring of patient with DOT & smear microscopyRNTCP Treatment Regimens2H3R3Z3 / 4H3R3 New smear negative and extra-pulmonary, not seriously illCat III2H3R3Z3E3S3 / 1H3R3Z3E3 / 5H3R3E3 Previously treated smear positive (relapse, failure, treatment after default)Cat II2H3R3Z3E3 / 4H3R3 New smear positive; seriously ill smear negative; seriously ill extra-pulmonaryCat INote: Any patient, pulmonary or extra-pulmonary, who is known to be HIV positive based on voluntary sharing of results and/or history of ART, is considered as seriously ill.

2 Such patient should get Cat-I treatment (if new), or Cat-II treatment (if previously treated)ProgrammeMonitoringRNTCP monitoringstrategyisbasedon: Reviewmeetings:usingstandardindicatorsan dchecklists Internalevaluation:2distictspermonthpers tateusingstandardprotocol Monitoringindicators:Exhaustivelistofind icatorsforalllevelsofmonitoringrKey programmemonitoring indicators TBsuspects/chestsymptomatics(subjectswit hcough>2weeks)examinedforsputumexaminati on Proportionofsymptomaticswithpositivesmea r Newsmearpositivecasedetectionrate ProportionofsmearpositiveoutoftotalnewPT Bcases Proportionofdiagnosedsmear-positivepatie ntswhowereinitiatedontreatment Smearconversionattheendof2/3monthsoftrea tment TreatmentoutcomeattheendoftreatmentProgr ammeSurveillance SystemPeripheral HealthInstituteDistrict TB CentreCentral TB DivisionState TB CellTuberculosis UnitMonthly ReportQuarterly ReportQuarterly ReportQuarterly FeedbackQuarterlyFeedbackSystem electronic from district level upwardsSince implementation >48 million TB suspects examined >13 million ptsplaced on treatment > million lives savedKey achievements of RNTCPA chievements in line with the global targets55%56%59%69%72%66%66%70%72%72%72% 84%85%87%86%86%86%86%87%87%87%0%10%20%30 %40%50%60%70%80%90%100%20002001200220032 004200520062007200820092010 Annualised New S+ve CDRS uccess rateFull country coverage450 Million population coverageTreatment outcome of smear

3 Positive cases registered under DOTS 4Q 2009 New sm + cases (N=143852)Re Rx cases (N=25443)88%4%2%5%1%Rx successDeathFailureDefaultTr. Out70%8%6%14%2%What is Evaluation ? Systematic collection of information about the activities, characteristics & outcomes of programs Why do we need to evaluate?Programme Evaluation helps to: assess the programme performance make judgments about the program improve program effectiveness and/or inform decisions about future program development Evaluations should be done at regular intervalsWhen do we evaluate Evaluationsshouldbedoneatregularinterval s InIndia, RNTCP evaluationisbeingdoneatthreelevels Inter-districtevaluationsbythestateatqua rterlyintervals(2districtseachquarter) Externalevaluationbyacentralteam(>2distr ictseachquarter) Internationalevaluationat3-yearlyinterva lWhat to evaluate Evaluationshouldincludetheimportantindic atorsfortheprogramme Whethertheprocessesareinplace Whetheroutputs,intermsofpatientsdetected &cured,aremeetingthebenchmarks ImpactevaluationEvaluation of RNTCP Process & outcome Evaluation Impact Evaluation Evaluation by funding agenciesIssues to be looked into during Evaluation Organization of TB services in the State Political & administrative commitment Capacity of the State TB Cell (STC)

4 In programme Monitoring Capacity of the STC in financial Monitoring Human resources Drug management system Involvement of other health sectors (public & private) Assess Advocacy Communication Social Mobilization (ACSM) activities Standard programme Monitoring indicators TB/HIV activities Intermediate Ref. Laboratory (IRL) & management of MDR-TB Any other issuesProcess Evaluation of RNTCPB eing done at different levels: Evaluation at review meetings at district & state levels Internal Evaluation Those conducted by states Those by CTD External Evaluation (Joint Monitoring Mission at a frequency of 3 years)Regular Evaluation Performanceindicatorsaremonitored&evalua tedat: Thesub-districtlevelthroughmonthlymeetin gsatdistrictlevel Districtlevelthroughquarterlymeetingsats tatelevelwithDTOs Statelevelbythecenterevery6monthsQuarter lyreportsareregularlypublishedonthewebsi te( )Internal Evaluation by the State Eachstateselect2-districtsbasedonperform ance(onegood&onebadperformingdistrict) EvaluationdonebyanotherdistrictDTO& RNTCP consultant(4days) STOisamemberoftheteam Report&recommendationssenttocentralTBdiv ision&STO Correctiveactionstakencheckedatnextquart erlyreviewCentral level internal Evaluation Onestateeachmonth,standardizedformsusedf ordatacollection&reporting Purposivesamplingof2-districts 5 DMCs:oneattheDTC,4randomlyselected,addit ionallyoneDMC(medicalcollege/NGO/Private /tribal/urbanslum) VisitalltheDOTcentersintheDMCarea&3morei nthedistrictwithuniquecharacteristics Visit5 NSPcases(randomlyselected)ineachofthe5 DMCs Visit2pts.

5 (notNSP)fromtheDOTcentersatDTC&TUlevel Visitatleast3pediatricpatients Reviewstatelevelissues Oralfeedbacktothelocalstaffduringvisit AppriseDTOonsalientobservationsattheendo fIE Communicatesalientobservations&recommend ationswithstateofficials(DHO&Secretary,H ealth) Submitthesummaryevaluationreporttocentra lTBdivision&stateauthoritiesCentral level internal evaluationCentralevaluationhelpsto: Identifyfactorsleadingtogoodperformance, thatcouldbereplicated Analysereasonsforpoorperformancetotakeco rrectiveaction Ultimateaimbeingtoimproveperformance Actiontakenonrecommendationstobesubmitte dCentral level internal evaluationExternal Evaluation ReferredtoasJointMonitoringMission Conductedoncein3-years 4reviewsconductedsofar:2000,2003,2006&20 09 national &internationalexpertsfromvarious organizationsIssues identified by JMM 2006 Rapid expansion outpacing the management capacity Weak general health system Frequent transfers of trained staff Dependence on external technical & financial assistance Quality of DOT ?

6 Promoting drug resistant TB Lack of quality assured culture/drug susceptibility testing facilities Wide prescription of second line drugs ? Promoting XDR TB Inadequate involvement of private sector including medical colleges Limited availability of decentralised HIV testing TB HIV collaborative activities pose burden on TB programme managers Implementing infection control Implementing ACSM activitiesJMM RecommendationsIndia 2009 Main Recommendations Politicalcommitment,management&healthsys temstrengthening InlinewiththeStopTBStrategy,GoI& RNTCP toaimtoachieveuniversalaccessforallforms ofTB,goingwellbeyondthe2005targetsofatle ast70%CDR&85%treatmentsuccess. Tomobilizegreaterresources(bothfinancial &human)&inunderperformingstates&district s,toenhancepolitical&administrativecommi tment&improvesupervision& Monitoring Reviewthefinancialrequirements&commitmen tsfortheperiod2010to2015,includingthoseo fGoI&externalsources,toensurethatsuffici entresourcesareavailablefortheexpecteddr amaticincreaseincostsfortheplannedMDR-TB managementscaleup& Evaluation Repeatcommunitybasedsurveyinaruralareaof Tamilnadu,TRC,Chennai TwoARTI surveycompleteddiseaseprevalencesurveysa t5sentinelsites DrugResistanceSurveillanceARTI survey AnationwidesurveytoestimateARTI wasconducted& RepeatsurveyhasbeencompletedSentinel surveillance Sixsiteshavebeenidentifiedforsentinelsur veillanceoftheprevalenceofdiseasesurveyt obedoneatperiodicintervals FirstroundofsurveyhasbeencompletedDrug resistance surveillance TRChasbeenmonitoringDRSintheprojectareaa mongpatientsadmittedfortreatment Initialsurveillancehasbeencarriedoutintw ostates Planstobedoneinmorestates ExternalfundingfortheRNTCP Worldbank:>60%ofRNTCP USAID:Haryana GFATM.

7 AP,Chhattisgarh,Jharkand,Uttaranchal,Ori ssa&partsofBiharandUP DFID:FordrugsthroughGDF/WHO(almosthalfof thedrugrequirementofRNTCP suppliedbyDFID)Donorevaluationsonfinanci ngandHRoncein6m/oneyearDonor evaluationsSummary RNTCPI nternalEvaluationhelpstotakecorrectiveac tions Regularmonitoringandinbuiltprocessevalua tionshelpedtheprogrammeimplementation BaselineswerenotavailablesoImpactEvaluat ionswereplannedfewyearsbefor