DR-TB HIV Coordinator: Integration of NTEP with the Health System

Overview of the organisational structure of the health system in relation to the National TB Elimination Programme (NTEP) is shown in the figure below.

Image

• Sub-centre: Most peripheral units under the public health system are designed to bring about behavioural change and provide preventive health care services.
• Primary Health Centre (PHC): First contact point between the village, community and the medical officer envisaged to provide integrated, curative and preventive health care.
• Community Health Centre/ Sub-district Hospitals: Serve as a referral centre for four PHCs and provides facilities for obstetric care and specialist consultations.
• Peripheral Health Institute (PHI): Most Peripheral Unit under the NTEP provides TB treatment and diagnostic services to the population.
• Tuberculosis Units: Nodal point for TB elimination activities in the sub-district level and are also responsible for stacking and supply of drugs to the PHI.

Resources

• Operational Guidelines for TB Services at Ayushman Bharat Health and Wellness Centres, CTD, MoHFW, India, 2020.
• National Strategic Plan 2017-2025 for TB Elimination in India, CTD.

Assessment

• The public health system in India through the National Health Mission (NHM) visualises the attainment of Universal Health Coverage (UHC) for all its citizens, which provides access to equitable, affordable and quality health care services, which is also accountable and responsive to the needs of the people.

• Under the umbrella of NHM, the National TB Elimination Programme (NTEP) ensures the provision of free TB services (diagnostics and drugs) and management of TB as per the Standards for TB Care in India (STCI).

• Furthermore, the NHM, under the Ayushman Bharat initiative has taken measures to strengthen the primary care facilities including Primary Health Centres (PHCs) and Sub Health Centres (SHCs) in the Ayushman Bharat Health & Wellness Centres (AB-HWCs).

Need for integration of NTEP with the Health System at Different Levels

1. Closer to community TB Services: The integration of TB services with the health system provides an opportunity for the TB programme to leverage the resources under the Ayushman Bharat initiative to take TB interventions closer to the community which were otherwise provided at the primary care level.
2. Improved population coverage: Active empanelment and HWC database will help to monitor and identify the left-out population and contribute significantly to the NTEPs case finding activity coverage.
3. Improved population health outcomes: Improved availability, access and utilisation of advanced TB treatment services under the ambit of UHC is essential in reducing morbidity and mortality from TB which may in turn also contribute to overall equitable health outcomes.
4. Reduced out-of-pocket expenditure: The integration will improve the access to TB services, assure within-reach TB medicines and diagnostic services, provide linkages for care coordination with Medical Officers/ specialists across various levels of care, etc., all of which will reduce the catastrophic expenditures faced by the patients and their families.
5. Decreased crowding at the secondary and tertiary health facilities: A strong network of peripheral level TB care services would facilitate in reduction of the overcrowding and the case burden at the secondary and tertiary facilities, which could be utilised for cases with follow-up referral to higher level facilities.
6. Increased responsiveness and addressal of social determinants of TB: Provision of TB treatment at the nearest point of care for the communities and engaging the most peripheral workers from the health system like the Accredited Social Health Activists (ASHA) in the TB programme may lead to comfort in accessing the care by the patients and also enable addressing psycho-social determinants of TB.

Resources

• Operational Guidelines for TB Services at Ayushman Bharat Health and Wellness Centres, CTD, MoHFW, India, 2020.
• National Strategic Plan 2017-2025 for TB Elimination in India, CTD.

Assessment

The National Health Mission (NHM) was launched by the Government of India in 2013, subsuming the National Rural Health Mission (NRHM) and National Urban Health Mission (NUHM). Figure 1 shows the history of the NHM.

The vision of NHM is “Attainment of Universal Access to Equitable, Affordable and Quality health care services, accountable and responsive to people's needs, with effective intersectoral convergent action to address the wider social determinants of health.”

Image

Figure 1: History and Make-up of the NHM; Source: Annual Report 2015-16, Ministry of Health and Family Welfare (MoHFW)

NHM further aims to support the existing national programmes of health and family welfare (Figure 2) including reproductive and child health, malaria, blindness control, iodine deficiency, filariasis, kala-azar, tuberculosis (TB), leprosy, and integrated disease surveillance.

Image

NHM and the National Tuberculosis Elimination Program (NTEP)

Integrating the NTEP with the health system increases the effectiveness and efficiency of TB care and control. India's TB control programme has been mainstreamed efficiently with the NHM.

The overall responsibility for the financial management of the NTEP is with the MoHFW, Director General of Health Services (DGHS) through the NHM.

At the state level, the State Health Society or its equivalent under the NHM of the state manages the financing of the TB Control Programme.

At the sub-district level, the TB Unit (TU) is the nodal point for TB control activities. TUs are based mainly in NHM health blocks with the aim of aligning with the NHM Block Programme Management Unit (BPMU) for optimum resource utilization and appropriate monitoring.

Resources

• Annual Report 2015-16, Chapter 2: NHM, Ministry of Health and Family Welfare (MoHFW).
• Information on the NHM, NHM India, 2020.
• NTEP Training Modules 1-4 for Programme Managers & Medical Officers, 2020.

The private sector for tuberculosis (TB) care is everything outside the ambit of government-run public health initiatives. It consists of a wide range of providers from individual medical practitioners of many different systems of medicine, including:

• Modern medicine
• Indian systems of medicine
• Homeopathy
• Paramedics
• Traditional healers
• Private hospitals and nursing homes
• Non-governmental organization-run hospitals
• Corporate sector health care institutions

As per the National Sample Survey Organization report of the 75th round, more than 70% of patients seek care in private clinics or hospitals.

Challenges with TB care in the private sector:

• Delays in diagnosis
• Over-diagnosis of TB due to an over-dependence on X-rays
• Use of multiple non-standard regimens for inappropriate durations
• Lack of a mechanism to ensure the full course of treatment and to record treatment outcomes

Regulatory tools to improve TB care services: The following are existing regulatory tools to improve TB care services in the private sector:

• Standards for TB care in India
• Mandatory TB notification on Nikshay
• Ban on sero-diagnostics
• Amendments in H1 schedule

Regulatory tools, however, are limited, and partnership is preferred. 

Steps/approaches to strengthen private sector engagement:

Partnership approaches include:

• An expanded acceptance by National TB Elimination Program (NTEP) of internationally approved diagnostic and treatment protocols
• Reliance on market forces rather than normative exhortation, that is, engaging and prioritising health care providers that offer the highest market value
• Increased use of accreditation and contracting

Other NTEP initiatives include:

1. Outreach to private laboratories
2. Increased control of TB drugs
3. Innovative use of information and communication technologies for TB notification and treatment adherence monitoring

NTEP has systematically mapped private healthcare providers (single and multispecialty hospitals), private laboratories and chemists in the Nikshay online portal through which these health facilities can notify TB patients.

Resources

• Training Modules (1-4) for Programme Managers & Medical Officers, 2020.
• Key Indicators of Social Consumption in India: Health, NSS 75th Round Report, Ministry of Statistics and Programme Implementation, 2019.
• JEET Brochure.

Kindly provide your valuable feedback on the page to the link provided HERE

Integrated patient-centred care and prevention are one of the pillars of the End TB strategy. This requires TB services to be made affordable and accessible by integrating them with the general health system. 

In 2005, the National Rural Health Mission (NRHM) was established and was merged with the National Urban Health Mission (NUHM) in 2013, to form the National Health Mission (NHM).The National TB Elimination Programme (NTEP) is a flagship programme under the NHM and fund allocation to NTEP occurs through the NHM.

NTEP integrates with the public healthcare system at various levels as follows:

• Community level – Accredited Social Health Activists (ASHA)/ Community Health Volunteers (CHVs)/ Multipurpose Workers (MPWs)
• Ayushman Bharath Health and Wellness Centre - Sub Health Centre (ABHWC - SHC)
• Ayushman Bharath Health and Wellness Centre - Primary Health Centre (ABHWC - PHC)
• Community Health Centre (CHC)
• District/ Taluka hospital
• Medical Colleges
• Other health institutions in the public sector – ESI, railways, ports and the ministries of mines, steel, coal, etc.

Note: As far as NTEP is concerned, a Peripheral Health Institution (PHI) is a health facility headed by a Medical Officer

TB services are provided free of cost through the public health system.

Services provided include:

1. Advocacy, Communication and Social Mobilisation (ACSM) and Information Education and Communication (IEC)
2. Screening for TB – Active Case Finding (ACF), Passive Case Finding (PCF), Intensified Case finding (ICF)
3. Diagnosis of TB and drug resistance – Designated Microscopy Centre (DMC) or TB diagnostic centres. Some of the PHIs themselves act as DMCs or Sputum Collection Centres
4. Treatment for DS-TB and H Mono/Poly DR-TB through PHIs
5. Treatment for DR-TB through District/Nodal DR-TB Centres
6. Treatment Support through out treatment course
7. Clinical follow-up and comorbidity management
8. Referral services for those with Adverse Drug Reactions (ADRs)
9. Screening for Tobacco and Alcohol addiction and linkage to de-addiction services
10. TB preventive therapy
11. Data management in Ni-kshay

References

• Technical and Operational Guidelines for Tuberculosis, 2016.                        
• National Strategic Plan 2017-2025 for TB Elimination in India, CTD. 
• Detect-Treat-Prevent-Build: Strategy for TB Elimination in India by 2025, Indian J Community Med., 2018.

Assessment

Ayushman Bharat (AB) is an attempt to move from a selective approach to health care to deliver comprehensive range of services spanning from preventive, promotive, curative, rehabilitative and palliative care. AB-HWCs are envisaged to deliver expanded range services that go beyond maternal and child health care services to include care for non-communicable diseases, palliative and rehabilitative care, oral, eye and ear nose and throat care, mental health and first level care for emergencies and trauma, including free essential drugs and diagnostic services.

It has two components which are complementary to each other.

1. Under its first component, 1,50,000 Health and Wellness Centres (HWCs) will be created to deliver Comprehensive Primary Health Care, which is universal and free to users, with a focus on wellness and the delivery of an expanded range of services closer to the community.
2. The second component is the Pradhan Mantri Jan Arogya Yojana (PM-JAY) which provides health insurance cover of Rs. 5 lakhs per year to over 10 crore poor and vulnerable families for seeking secondary and tertiary care.

On 14th April 2018, the Honorable Prime Minister of India launched the first Health and Wellness Centre at Jangla, Bijapur, Chhattisgarh. Health Sub-Center (HSC), PHC (Primary Health Center) and Urban PHCs are currently being upgraded to reach a goal of 1.5 lakhs AB-HWC by 2022.

The National TB Elimination Program (NTEP) has also integrated TB services as part of the health and wellness center service delivery package.

Resources

• Operational Guidelines for TB Services at Ayushman Bharat Health and Wellness Centres, MoHFW, 2021.
• Ayushman Bharat - Health and Wellness Centre Website, Government of India.

Kindly provide your valuable feedback on the page to the link provided HERE

Medical colleges in the country are integrated with the National TB Elimination Programme (NTEP) to widen access and improve the quality of TB services. Medical colleges provide specialized services for seriously ill TB patients.

The integration of medical colleges in the program is in a structured task force mechanism at different levels:

• National
• Zonal
• State  

One national and six zonal task forces have been formed under the programme along with task forces for all states. A core committee is also formed in each medical college. These task forces are created with defined roles and responsibilities for the effective involvement of medical colleges in the programme.

Core Committee

Every medical college will have core committees representing various hospital departments and NTEP nodal officers. These committees meet quarterly and review the implementation of the program in the medical college.

Functions of the core committee:

• They organise sensitisation workshops and training for faculty members, postgraduates, undergraduates, interns, paramedical staff, etc. ​
• Ensure that teachings on TB/ NTEP form part of the curriculum for all medical colleges.
• Coordinate between various departments so that patients get the services under one roof.
• Coordinate with the district TB programme. ​

​Role of Medical College in NTEP

1. Medical colleges coordinate with the district TB programme for participation in quality assurance, supervision, monitoring, review and evaluation.
2. Operational research is one of the important activities of medical colleges. 
3. Every medical college should have TB detection facility and treatment support centres. These centres are equipped with trained additional human resources such as medical officers, laboratory technicians and TB health visitors.
4. The National Medical Commission insists that all Medical Colleges should also have facilities to manage DR-TB patients.
5. Medical colleges undertake advocacy for the programme.
6. Medical colleges also functions as peripheral health institutes (PHI), maintain TB notification registers and submit monthly PHI reports​: They have Nikshay user access and need to enter TB-related data on a real-time basis. 

Resources

RNTCP Technical and Operational Guidelines for Tuberculosis Control in India, 2016.

Assessment

Integrated Counselling and Testing Centre (ICTC) is a hub where HIV Counselling and Testing Services (HCTS) are offered to an individual of his/her own will or as suggested by a medical care provider.

Types of ICTC

1. Standalone ICTC (SA - ICTC)

2. Facility integrated ICTC (F - ICTC)

The SA-ICTC facility is a confirmatory facility and it should be located at an easily accessible place with proper signages to direct and guide people to the location.

The SA-ICTC facility should consist of at least two rooms, one for counselling and the other for testing.

ICTCs are aligned to the National TB Elimination Programme (NTEP) diagnostic facilities.

• All individuals attending the ICTC are screened for the four symptoms of fever, cough, night sweats, and weight loss.
• Presumptive TB cases are referred for TB diagnosis to TB Detection centres(TDCs).
• Link the referred individual to the NTEP centre by providing a linkage form in Triplicate.
• Provide them with a duly filled NTEP referral form for diagnosis to fast track. 
• Line list of all the Presumptive TB should be maintained and should be reviewed with NTEP monthly to ensure that all the cases have undergone testing.

Resources

• National HIV Counselling and Testing Services (HCTS) Guidelines, National AIDS Control Organisation, Government of India, 2016.

Assessment

Facility-integrated Integrated Counselling and Testing Centre (F-ICTC) takes HIV Counselling and Testing Services (HCTS ) closer to the people, increasing the uptake of services while reducing transportation costs and waiting times. F-ICTC s can be mobile or fixed.

Proper signage should direct and guide people to reach the F- ICTC.

The health facility should earmark a suitable room to ensure privacy and confidentiality and with good cross-ventilation to prevent air-borne infection.

Any positive HIV results at F-ICTC are only provisional - The facility uses whole blood finger-prick test kits for HIV screening.

If found reactive on HIV screening, link the individual to the linked SA-ICTC for confirmation of HIV diagnosis and further necessary action, using the Linkage Form. 

If found non-reactive on HIV screening, the laboratory report duly signed by the medical officer should be given to the individual during post-test counselling on the same day as the screening.

Verbal screening for the four symptom complex of TB is done for all the clients and appropriate referral to NTEP diagnostic facilities if indicated. The provisions for Presumptive TB testing is applicable for ICTCs too.

Resources

• National HIV Counselling and Testing Services (HCTS) Guidelines, National AIDS Control Organisation, Government of India, 2016.

Assessment

Anti-retroviral Therapy (ART) Centre is a facility to provide a comprehensive package of care, support and treatment services to persons living with HIV/AIDS (PLHIV).

ART Centre - TB  Diagnosis and Treatment  

Image

DR TB   cases are referred to  DR TB centre.

Referrals for TB  diagnosis are documented in the HIV TB line list which will be updated with the help of Senior Treatment Supervisor (STS) according to the test reports. 

TB HIV registers are maintained in the ART centres to document TB cases.

INH preventive Therapy (IPT)  - is initiated for all eligible PLHIV  at ART centre

Resources

• Operational Guidelines for ART Services, NACO, GoI, 2012.
• TB/ HIV Module for ART Centre Staff National AIDS Control Organisation and Central TB Division, Ministry of Health & Family Welfare, GoI, 2010.

Assessment

Link ART Centre (LAC) aims for easy accessibility of treatment services for People Living with HIV (PLHIV) by reducing the distance, cost, and waiting hours for Anti-retroviral Treatment (ART) and thereby increasing treatment adherence. They are linked to a Nodal ART centre.

Link ART Centre Plus (LAC Plus) is LAC which performs pre-ART management also. This will help to bridge the gap between Integrated Counselling and Testing Centre (ICTC) and Care, Support & Treatment (CST) services. These patients shall be followed up at LAC plus till they become eligible for ART or are referred to the ART centre for any other reason.

In addition to the existing infrastructure of ICTC where LAC is being established, at least one additional room is required for the nurse provided by the institution, for record keeping and other LAC functions.

Only patients from the designated nodal ART centre shall be linked to the attached LAC/ LAC plus.

Patients satisfying all of the following conditions shall be linked out to Link ART centres:

1. PLHIV on ART for a minimum of six months at the nodal ART centre

2. Those who have exhibited an increase in CD4 count and clinical improvement after 6 months of initiating ART

3. Do not have any active OI

4. The patient is a resident of an area closer to the LAC than to the nodal ART centre

5. Those who are willing to be linked out and collect their ARV drugs from the LAC, once the above conditions are fulfilled

Copy of Link out/in format to be exchanged between nodal ART centre and LAC while linking out or linking in the patients and a soft copy of these are to be maintained by both nodal ART centre & LAC/ LAC plus in a separate folder.

LAC/ LAC plus shall not initiate/ modify ART in any patient at any time.

Resources

• Operational Guidelines for Link ART Centres and LAC PLUS, NACO, Department of AIDS Control, MoHFW, GoI, 2012.

Assessment

Centres of Excellence (CoE) in HIV care were established with an objective to set up model treatment centres, impart high-quality training, and undertake operational and clinical research about HIV/ AIDS on a larger scale.

Structure and Activities of Centre of Excellence

Image

The Anti-retroviral Treatment (ART) CoE are located in medical colleges and tertiary care centres of high technical repute. The CoE ideally should have an environment that is comfortable for the care provider as well as the beneficiary to obtain optimal results.

• The ART centre of the institution should be an integral part of the CoE as the key centre providing clinical HIV care for persons infected/ affected by HIV.
• There should be a functional integration of the ART centre with CoE.
• Paediatric CoE/ paediatric department, Prevention of Parent to Child Child Transmission (PPTCT) services, laboratory services and inpatient care in the institution should be linked to the CoE to ensure comprehensive HIV care.

Manpower in CoE

• Programme Director - Faculty of the institution associated with the National AIDS Control Organisation (NACO) programme 
• Deputy Programme Director- identified from the institution

Additionally recruited staff on a contract basis include:

• Research Fellow (Clinical) - 1
• Research Fellow (Non-clinical) - 1
• SACEP Coordinator -1
• Data Analyst – 1
• Training and Mentoring Coordinator – 1
• Laboratory Technician – 1
• Nutritionist – 1
• Outreach Workers/ Social Workers- 2

CoE Team - Multidisciplinary team headed by the Head of the institution. It should consist of trained faculty from the departments of Medicine, Microbiology, Obstetrics & Gynaecology, Paediatrics, Community Medicine, Dermatology and Venereology. This team reviews the functioning of the CoE. Members of this team will also be engaged as resource persons in various training programmes organised by NACO/ State AIDS Prevention and Control Societies (SACS) after their certification as national trainers.

Steering Committee - Headed by the head of the institution. Members of this Committee should include the Programme Director, Deputy Programme Director, Director of concerned SACS and a NACO representative. This committee should meet once in 3 months to review of the functioning of CoE and to sort out any issues related to its functioning.

State AIDS Clinical Expert Panel (SACEP ) consists of - 1) Programme Director of CoE/ Deputy Programme Director/ Nodal Officer of ART centre 2) External ART expert 3) Regional Coordinator/ Joint Director (Care Support and Treatment)/ Consultant (CST) at SACS.

Treatment Linkage to CoE

Patients from ART centres experiencing treatment failure with first-line ART or drug toxicity are referred to the CoE for further evaluation and second-line treatment/ Alternate first-line treatment as per the linkage plan.

Resources

• Scheme for Centres of Excellence in HIV Care, NACO, MoHFW, GoI, 2012.

Assessment