Vous êtes sur la page 1sur 248

MODULE 5 to 9

Module 5 :

1-82

Programme Monitoring
Module 6 :

83-153

Programme Management
Module 7 :

157-198

Programme Logistics Management Including preventive


maintenance
Module 8 :

201-221

Program Supervision and Evaluation


Module 9 :
Managerial Skills for TB Program Managers

225-244

Table of Contents
Module - 5
Programme Monitoring
Learning Objectives ....................................................................................................................
Follow the Report or Feedback ..................................................................................................
Analysis of the quarterly report of case finding .........................................................................
Quarterly report on sputum conversion ....................................................................................
Quarterly report on treatment outcome ....................................................................................
General Information ...................................................................................................................
Procedure for preparing & reviewing quarterly report on Treatment outcome .......................
TB treatment outcome of HIV positive patients ........................................................................
Report on programme management and logistics .....................................................................
PHI level monthly report on programme management and logistics ........................................
Quarterly report on programme management and logistics TU level .......................................
Quality of DOTS implementation ...............................................................................................
Medications, Consumables and equipments .............................................................................
Quarterly report on programme management and logistics state level ....................................
Analysis of quarterly reports ......................................................................................................
Provision of feedback .................................................................................................................
Method of providing feedback ...................................................................................................
Time Schedule for feedback ........................................................................................................
Record to be used for preparing the reports ..............................................................................
Quarterly report on programme management and logistics state level Format .......................

1
2
10
13
20
22
28
29
33
34
38
40
41
45
49
51
52
52
52
71

Training Course for Program Manager

MODULE 5

Learning objectives.

Monitoring of the programme


Flow of reports including time schedule
Preparation of quarterly reports on
Case finding
Sputum conversion of new and previously treated cases
Treatment outcome
Programme logistics and management
Data management, including analysis of programme indicators, quality of
reports and actionable feedback
Electronic data management system in RNTCP

Introduction
In the previous module we have learnt about registering of cases in TB register and
monitoring of the treatment of the patient till the declaration of the treatment outcome. In the
ensuing module we will learn how to utilize the information recorded in the TB register for
generation of periodical reports on the programme activities and learn to monitor the
performance of the programme through these reports.
Monitoring: It is a centralized systematic ongoing collection, collation, analysis and
interpretation of the data with a view to detect any deviations from the expected norms
followed by dissemination of feedback information to the peripheral authorities for corrective
actions.
Monitoring is a process of observing whether an activity or service is occurring as planned.
Monitoring aims at identifying any diversion from a planned course of action and allowing
timely solutions to problems In management, the continuous oversight of the
implementation of an activity seeking to ensure that input deliveries, work schedules,
targeted outputs, and other required actions are proceeding according to plan.

Monitoring of the programme


Monitoring is an essential component of the programme implementation. It is undertaken at
different levels:
1.
2.
3.
4.
5.

National Level Central TB Division


State Level - State Health Society and State TB Cell with the support of STDC
District Level - District Health Society and District TB Officer
TB Unit Level Medical Officer TB Control
Peripheral health institutions Medical Officer (In-charge)
1

Training Course for Program Manager


Maintenance of accurate records and timely preparation and dispatch of validated reports is
a prerequisite for successful monitoring. Different formats of records and the monthly PHI
report have been described in detail in relevant modules.

Quarterly reports
Under the monitoring system there are four types of quarterly reports. These reports
furnish information on case finding, sputum conversion and treatment outcome of a
quarterly cohort of patients. The fourth one is a quarterly report on the programme
management and logistics report (PMR) generated at different levels PHI (monthly), TU,
District and State.

Flow of reports and feedback:


The monthly PHI level PMR is prepared by the MO of the PHI and sent to the district and
TU. At the TU a quarterly PMR is prepared by the MOTC with support of STS/STLS and
sent to the DTO.
Quarterly reports on case finding, sputum conversion and treatment outcome are prepared
at the TU level from the TB register. The STS is responsible for preparing the reports
mentioned above under the overall supervision of the MOTC at TU level. The MOTC is
responsible for validating and signing the reports and sent it to DTO.
The quarterly reports received from all the TUs in the district are consolidated at
District TB Centre. District TB Officers in turn are responsible for reporting the same to the
state level authorities [STC and STDC] and CTD. The reports are consolidated at STC
and sent to CTD. The reports are analysed at the STC/STDC and feedback given to
districts. The quarterly reports are also analysed by CTD and feedback is provided to the
state for corrective actions. All the above reporting activities are undertaken on a quarterly
basis from TU to central level. A diagrammatic flow chart is provided below depicting the
monitoring process.
Flow of reports
Tuberculosis Unit
Quarterly Reports

District TB Centre
Feed Back
Electronic Transmission
Feed back

Central TB Division

State TB Cell

Quarterly Reports

Training Course for Program Manager

Cohort: In RNTCP, a cohort is a group of patients who were registered for treatment in a
specified area (TU, district, state, country) over a specified period of time (quarterly,
annual). The date of registration in the TB register is used to demarcate the cohort.
The specified quarterly cohort periods are:
Quarter

From

To

First

1st January 31st March

Second

1st April

30th June

Third

1st July

30th September

Fourth

1st October 31st December

Quarterly report on Case finding:


Type of cases to be reported
In this report, total number of all tuberculosis patients registered in a quarter under DOTS
regimen viz., new or previously treated are recorded. The patients put on RNTCP NonDOTS regimen and transfer-in cases are not reflected in the report though they are
registered in TB register. This information is compiled at the level of the TB Unit from the
TB Register.

Expected timeline for submitting the reports


The monthly and quarterly reports should be completed and submitted to higher levels as
mentioned below:
Quarter

Preparation and
submission of reports
from PHI

Preparation and
submission of reports
from TU to District

Last date for


submission
of district
reports from
District to
STC/STDC
and CTD

Last date for


submission of
consolidated
state reports
from State to
CTD

First

By the 5th of next month

7th April

24th April

30th April

Second By the 5th of next month

7th July

24th July

30th July

Third

By the 5th of next month

7th October

24th October

30th October

Fourth

By the 5th of next month

7th January

24th January

30th January

Training Course for Program Manager


Description of the format The format is to be referred while reading the quarterly
reports.
The quarterly report on case finding comprises of:
a. General information reflecting

The quarter under report (eg. 1Q, 2Q, 3Q, 4Q suffixed by calendar year)
Eg. Patients registered during the first quarter will be reported in the first month of
the second quarter to different levels as furnished in the table above.
Name of the TB Unit and its code number (as assigned by CTD)
Name of the reporter (Name of the MO-TC/DTO/STO)
Date of completion of the form (self explanatory)

b. BLOCK 1: This block contains the total number of new and previously treated cases
diagnosed and registered in a particular quarter.
New cases are subdivided into four columns comprising:

New smear positive pulmonary TB


New smear negative pulmonary TB
New extra pulmonary TB
New others

Previously treated cases are subdivided into four columns comprising

Relapse
Failure
Treatment after default
Others

Break-up of cases in the age group 0-14, 15 years and above and their total is provided for
both new and previously treated cases. Sex-wise break up is also provided for all new
cases and relapses among previously treated cases.
Block 1: All new and previously treated patients registered in the quarter.
Age

0-14 Yrs
15 Yrs
Total

Smear
positive
pulmonary
TB

New cases
Previously Treated Cases
Smear
Extra
Treatment
negative
Treatment
pulmonary Others Relapse
After
pulmonary
Failure
TB
Default
TB

Others

Total

Male
Female
Total

c. BLOCK 2: Break up of new smear positive pulmonary tuberculosis cases, age wise and
sex wise is provided in Block 2. This block facilitates drawing inferences on the
epidemiological trend and efficiency of the TB control measures currently in force.
4

Training Course for Program Manager


Block 2: New Smear Positive Pulmonary TB cases only: from Block 1
Age group 0 14
Male
Female
Total

15 24

25- 34

35 44

45 - 54

55 64

65

Total

d. BLOCK 3: The programme monitors the proportion of TB patients getting tested for HIV
to know prevalence of HIV infection among TB patients, thus ensuring appropriate HIV
care in TB patients. Block 3 furnishes information on TB-HIV collaborative activities and
provides information on total number of registered TB cases tested for HIV either before
or during treatment and number found to be infected.
Block 3: TB/HIV Collaboration
Of (a)
Number known to be HIV infected
(b)

Of all Registered TB cases, Number


known to be tested for HIV before or
during the TB treatment
(a)

Procedure for preparing & reviewing the quarterly report on case findings
BLOCK 1:

The pages pertaining to the quarter to be reported & reviewed are located in the TB
register. It can easily be located by going through the pages since the cases are
registered on a new page every quarter. For eg. Patients registered from 1st January
31st March.
Identify new and previously treated TB cases by age and sex in each page. Fill their
exact number in the appropriate box provided under summary at the bottom on the left
side of TB register on each page as soon as the page is completed.
Count the total number of similar cases in all the summary boxes of each page of the TB
register for the age group for the entire quarter. Their exact number (sum) is entered in
the appropriate boxes of the Block 1 of the quarterly report on case finding. For eg.
smear positive cases in the age group of 0-14 years of all the pages for the quarter in
the TB register are added and total of that is recorded in the box in Column 1 against 014 years row. The same procedure is adopted for all the types of cases.

BLOCK 2

This block contains age and sex-wise break up of only new smear positive cases
registered in a specific quarter of Block 1.
The new smear positive cases registered in all the pages pertaining to the quarter of the
TB register are identified in the seven age groups (0-14, 15-24, 25-34, 35-44, 45-54,
55-64, 65 & above) provided in the Block 2. Worksheet provided in the module may be
used for this purpose. These are internationally recognized age groups.
The number of new smear positive cases males, females and total should match with
those reported Block 1

Training Course for Program Manager


BLOCK 3

The purpose of this block is to provide information on the process of ascertaining HIV
status of TB patients.
Total number of TB patients whose HIV status is known either before diagnosis or
during diagnosis and treatment is to be reflected in column (a). Enter the sum of all TB
patients registered in the quarter with their HIV status recorded as either positive (P) or
negative (N).
Total number of TB cases found HIV positive either before diagnosis or during diagnosis
and treatment is to be reflected in column (b). The sum of all TB patients registered in
the quarter with their HIV Status recorded as positive (P) in the TB register.
It is to be noted that number of patients known to be HIV positive may be less than the
number that will ultimately be reported in the treatment outcome quarterly report, as it is
expected that some will undergo HIV testing during the course of treatment after the
case finding report is submitted.

EXERCISE 1
Using the five pages of the Tuberculosis Register in Exercise Workbook 3, complete all the
three Blocks of the Quarterly Report on Case Finding. Use the information from the
corresponding summary table at the bottom of the Tuberculosis Register for completing the
worksheets meant for Block 1, 2 & 3 respectively. The total of all types of cases thus
arrived at will be transferred on to the appropriate cells in the block 1,2 & 3 of the quarterly
report on new and previously treated cases.
For completing worksheet, one tally mark (/) is put for each case. Four tally marks are
placed consecutively (////). Subsequently, when a fifth case is recorded four tally marks
already put are crossed (-). In this way each such group represents five cases. This method
of tally marking facilitates counting.
For convenience, easy understanding and execution of the exercise during training, it is
recommended that two trainees may be allotted one page of the TB register for exercise on
case finding. This can be tallied and entered in the Block 1 of the quarterly report on case
findings. This exercise will be facilitated by the facilitator.

WORKSHEET FOR COMPLETING BLOCK 1


Review every page of the TB Register for the quarter being reported. Put a tally mark(/) in
the appropriate cell and give the totals in the space provided. The summary available on
the left bottom of the first page of the TB register will help in filling up this worksheet. M & F
break up not needed for Previously treated cases except Relapse

Training Course for Program Manager


Quarterly Report on Case Finding WORKSHEET FOR COMPLETING BLOCK 1
New Cases

Page
Age
No. Group

NSP
M

NSN
M

NEP

Others

Previously Treated Cases


Previously
Treatment
Relapse
TAD
Treated
Failure
Others
M
F
M
F
M F M
F

1
2
0-14
Yrs.

3
4
5

Total
1
2
15
Yrs.

3
4
5

Total

WORKSHEET FOR COMPLETING BLOCK 2


Review every page of the TB Register for the quarter being reported. Put a tally mark(/) in
the appropriate cell below and give the totals in the space provided. Include only patients
who are new sputum smear positive pulmonary cases.
Page
No.

Age Group / Sex


0 14

15 24

25- 34

35 44

45 - 54

55 - 64

65
M

Total
M

1
2
3
4
5
Total
Note: The total number of NSP cases in block 2 should be equal to total of NSP cases in block 1 of the
quarterly report on new and previously treated cases.

Training Course for Program Manager


WORKSHEET FOR COMPLETING BLOCK 3
The summary table furnished at the bottom of the right side of the TB register will help in
filling up of this worksheet. Total number of cases tested for HIV and number known to be
positive in each page are entered under cells a and b respectively. Sum total of a and b
are entered in appropriate boxes of block 3 of the quarterly report.
Page
No.
1
2
3
4
5
Total

Of all Registered TB cases, Number


known to be tested for HIV before or
during the TB treatment
(a)

Of (a)
Number known to be HIV infected
(b)

Note: TB patients whose HIV status is unknown and for whom information is not available are not to be
included in cell (a).

Code Number #: ____________

15 24

25 34

1 quarter January, February, March


nd
2 quarter April, May, June
rd
3 quarter July, August, September
th
4 quarter October, November, December

st

0 14

# Code Number - Identification number of the area.

Notes: Quarterly :

Age
Male
Female
Total

55 64

Treatment
Failure

(b)

Total

Total

Others

Of (a)
Number known to be HIV infected

65

Treatment
After Default

Block 3: TB/HIV Collaboration

45 54

Relapse

Previously Treated Cases

Of all Registered TB cases, Number


known to be tested for HIV before or
during the TB treatment
(a)

35 44

Block 2: New Smear Positive Pulmonary TB cases only: from column above

Male
Female
Total

Block 1: All new and previously treated patients registered in the quarter
New cases
New smear
New smear
New extra
positive
negative
Others
pulmonary TB
pulmonary TB pulmonary TB
0-14 Yrs
15 Yrs
Total

Name of the reporter: ___________________________________ Signature: _______________ Date of completion of this form

Patients registered during _____________ quarter of 20 _____

Name of TU / District: ____________

(New and Previously Treated Cases of Tuberculosis)

Quarterly Report on case finding

REVISED NATIONAL TUBERCULOSOS CONTROL PROGRAMME

Training Course for Program Manager


Table 1A: Programme Performance Indicators based on Quarterly Report on Case
Finding
Indicator

Description

Calculation

Case notification rate


for New smear-positive
cases

The Case notification rate of new


smear-positive cases is the number of
new smear-positive cases registered for
treatment per 100,000 population in a
year.
The Case notification rate is important
for observing trends in case notification
over the years. This is calculated for a
year. This could be calculated for
various age groups and sex.
In India, the estimated incidence of
cases (used in programme planning at
national level) is 75 New smear-positive
cases per lakh per year. However there
are regional variations in this figure.

Numerator: The number of New


smear-positive cases registered in a
year in a defined area (TU, district
state or country). (If calculated
quarterly, annualize it by a multiplier
of 4)
Denominator: The estimated total
mid-year population of the area in
lakhs (TU, district, state or country).

Case detection rate for


New smear-positive
cases

It is the proportion of notified NSP


cases out of the estimated incidence of
smear positive cases in that population.
This is expressed as a percentage. This
indicator should ideally not be used at
levels below the district.This is because
of the heterogeneity of smear positive
TB incidence at local levels depending
on living conditions, socioeconomic
status, migration etc.
One of the objective of RNTCP is to
achieve and maintain a NSP CDR of at
least 70%.

Numerator:
Annualized/annual
NSP case notification rate X 100
Denominator: Estimated incidence
of smear positive cases /lakh
population

Other programme performance indicators from case finding reports include:


1. Proportion of new smear positive cases among all new pulmonary cases.
2. Proportion of new extra pulmonary TB cases among all new TB cases.
3. Proportion of smear positive previously treated cases among all smear
positive cases.
4. Proportion of new pediatric cases among all new cases, etc.
It is important to note that these indicators are to be analyzed for trend and regional
differences and any unexpected deviations should prompt programme managers to
look at the reason for the deviations and take appropriate actions.
Analysis of the quarterly report on case finding:
Quarterly Report is evaluated for correctness, consistency and completeness. For
example, the total in Block 1 for smear-positive new cases should be the same as the total
of Block 2.

10

Training Course for Program Manager


To analyze the data on new cases, the data of one quarter (or half a year or a whole year)
is compared with the data for the same period of the previous year. Reasons for any
unexpected increase or decrease in the number of new cases registered are to be
explored. Similarly other indicators regarding Case Finding should be analyzed (Table1B).
When there are variations from what is expected, possible reasons for variations are
sought. Some possible ways to investigate the reasons are listed below:
Table 1B: Case Finding Indicators and possible responses to the problems
Quarterly Report Indicator

Possible Actions

Expected:

Reported:

Ensure that :

New smear-positive
case detection rate:

Case detection
rate of New
smear-positive
cases is less than
50%

Community awareness is enhanced regarding the


symptoms of TB and availability of TB services.
Encourage utilization of those services by the
community.

at least 70%

Sputum smear microscopy is accessible to


patients. Adequate number of functional DMCs in
each TU. Where ever needed sputum collection
centers are established and linked to the nearby
DMC.
Every TB suspect in all peripheral health facilities
undergoes sputum smear examination
All contacts of sputum positive TB patients are
being screened irrespective of the duration of
cough
The laboratory technician is trained.
Good quality sputum samples are collected from
the suspects.
Two sputum smear examinations are done for all
TB suspects.
Sputum smear microscopy is done as per standard
operating procedure (expected smear positivity
rate is 5%15%).
Smear-negative slides, particularly those of
patients placed on treatment are reviewed
intensively.
All smear-positives cases recorded in the
Laboratory Register are started on treatment and
registered in the Tuberculosis Register.
All health care providers are involved in RNTCP

11

Training Course for Program Manager


Expected:
Proportion of
previously treated
smear- positive cases
out of all smear
positive cases should
maintain a steady
trend and ultimately
decline over the
years.
This indicator needs
to be carefully
interpreted in light of
the trend in Case
notification rates in
Relapse, TAD and
Failure cases. In an
area providing good
quality DOTS
services, the trend of
Failure, TAD and
Relapse cases should
decline over the
years.
Expected:
At least 50% of all
New pulmonary cases
will be smear-positive

Proportion of
previously treated
cases has
suddenly dropped
in comparison to
previous quarter.

Ensure that:

Proportion of
previously treated
cases has
suddenly
increased in
comparison to
previous quarter.

Ensure that:

Among New
pulmonary cases,
proportion of
smear-positive is
less than 45%

Ensure that:

Accurate history of previous treatment for


tuberculosis from any source is elicited carefully at
all levels in order to prevent misclassification of
previously treated cases as new cases.

History-taking is accurate and definitions are


correctly applied.
DOT is administered as per guidelines.

No patient should begin treatment without the


mandatory two sputum smear examinations.
The diagnostic algorithm is strictly adhered to.
Repeat sputum smear examination is done for
suspects who continue to have symptoms after a
full course of antibiotics.
There is no undue dependence on x-rays for
diagnosis (over-diagnosis) of sputum smearnegative patients.
Sputum microscopy is Quality assured.

Among New
pulmonary cases,
proportion of
smear-positive is
more than 70%

Ensure that:
Diagnostic algorithm is completely followed in
cases with initial two smear negative results.
During field visits, health workers track and
motivate the suspects to get repeat sputum
examined if symptoms persist.
Smear negative patient are not missed during
referral for X-ray chest.

Expected:
Proportion of new
pediatric cases out of

Very low
proportion of
pediatric cases
compared to

Ensure that:
All health care providers including pediatricians are
trained in RNTCP Pediatric guidelines

12

Training Course for Program Manager


all new TB cases
should maintain a
steady trend. Initially
there may be an
upward trend due to
programme
interventions and
ultimately decline over
the years

national/state
average

All children in contact of smear positive patients


are screened for symptoms and signs of TB during
initial home visit by health workers and referred to
the MO PHI for further investigation and
appropriate management.
Pediatric PWB are available and are in use.

Indicators on TB-HIV status

1. Proportion of registered TB patients with known HIV status.


(Total number of registered TB patients with Known HIV status / Number of all registered TB
patients)X100
This proportion will indicate the TB HIV case finding efforts and an increasing trend is expected
with good TB-HIV collaboration.
2. Proportion of registered TB patients found to be HIV-positive.
(Total number of TB patients found to be HIV positive / Number of registered TB patients tested
for HIV)X100
This proportion indicates the HIV positivity among the tested TB patients.
This number also gives an indication on the requirement for HIV care.

Quarterly report on Sputum Conversion


(New and previously treated cases registered 4-6 months earlier)
Sputum Conversion rate at the end of the intensive phase is a critical early indicator of
the effectiveness of programme implementation. If smear-positive patients take treatment
under direct observation in the intensive phase of treatment, sputum of nearly all patients
will convert to negative within three months.
Sputum examination at the end of the intensive phase is important because:

Sputum conversion is an early and sensitive indicator of the quality of programme


implementation. A low conversion rate indicates need for intensive supervision.

Patients whose sputum smears are still found to be positive at the end of Intensive
Phase, will receive another month of intensive phase of treatment, thereby improving
their chances for cure.

Documentation that patients are converting from smear-positive to smear-negative gives


patients and health workers confidence in RNTCP.

The quarterly report on sputum conversion should be compiled by reviewing the patients
under RNTCP DOTS, who were registered in TB Register 4-6 months earlier. For example,
if the quarterly reports are being prepared on 7th October 2010, the sputum conversion
report should include the sputum smear-positive patients registered in 2nd Quarter 2010
(April to June 2010). These are the patients who were included in the Quarterly Report on
Case Finding of 2nd Quarter 2010.
Calculation of sputum conversion rate involves the following steps:
The number of smear-positive patients of each type put on treatment under DOTS is
obtained from the Quarterly Report on Case Finding for the corresponding quarter.
13

Training Course for Program Manager

All patients started on treatment are included in the denominator, even if they have
died, defaulted, transferred out, or not had their sputum collected for examination.

The ratio is multiplied by 100 for obtaining percentage.

Sputum conversion
rate =

No. of sputum smear-positive converted to sputum


smear-negative at the end of intensive phase*
Total no. of sputum smear-positive patients
registered in that particular cohort.

100

*For calculating sputum conversion rate for new sputum smear-positive patients only, all those who converted at the end
of IP (at the end of two months) and at the end of extended IP (at the end of three months) should be added to obtain the
numerator. Previously treated Smear positive cases converted at the end of the extended intensive phase (at the end of
fourth month) is excluded from the numerator. This is because collection of this information would delay sputum
conversion reporting by one quarter without adding significant information. Therefore in the sputum conversion report,
there is no provision for reporting sputum conversion at the end of extended IP in previously treated cases.

The sputum conversion rate is not only an indicator of the efficacy of the treatment
regimen, but also of the effectiveness of programme implementation. Hence all efforts
should be made in obtaining the results of the follow up sputum examination at the end of
intensive phase of the patients transferred to different unit/district. Although sputum
conversion rates are determined for all different types of smear-positive patients, the most
important evaluation is that of new sputum smear-positive patients.
At least 90% of new smear-positive patients put on treatment are expected to become
smear-negative within 3 months of treatment.
Ensure that the numbers of new sputum positive cases in the sputum conversion report
matches with the numbers of new smear positive cases registered 4-6 months earlier, as
per the case finding report. Similarly, the numbers of sputum positive Previously treated
cases in the sputum conversion report should match with the total of the smear positive
previously treated cases (Relapse, Failure and TAD) in the corresponding case finding
report.
The sputum conversion rate is not only on indicator of the efficacy of the treatment regimen,
but also of the effectiveness of programme implementation. Hence, all efforts should be
made in obtaining the results of the follow up sputum examination at the end of intensive
phase of the patients transferred to different unit/district. Although sputum conversion rates
are determined for all different types of smear-positive patients, the most important
evaluation is that of new sputum smear-positive patients.
At least 90% of new smear-positive patients put on treatment are expected to become
smear-negative within 3 months of treatment.
Ensure that the numbers of new sputum positive cases in the sputum conversion report
matches with the numbers of new smear positive cases registered 4-6 months earlier, as
per the case finding report. Similarly, the numbers of sputum positive Previously treated
cases in the sputum conversion report should match with the total of the smear positive
previously treated cases (Relapse, Failure and TAD) in the corresponding case finding
report.
Cohort of patients for sputum conversion report:
The cohort of patients registered 46 months earlier will be assessed.
14

Training Course for Program Manager


Cohort of patients registered in the Quarter and the time of reporting
Registered During Reported in 1st week of
1st Quarter 2009

3rd Quarter 2009

2nd Quarter 2009

4th Quarter 2009

3rd Quarter 2009

1st Quarter 2010

4th Quarter 2009

2nd Quarter 2010

Procedure for preparing & reviewing quarterly report on sputum conversion


Source of information for preparing quarterly report on sputum conversion :

TB Register.
Quarterly Report on case finding of the quarter selected for determination of smear
conversion.

General information reflecting:

Name of the area and code number (TB Unit - Self explanatory)
Name and signature of the reporter (MO-TC/ DTO/ STO)
Date of completion of this form (Not later than 1st week of the 3rd quarter in cases of
patients registered in 1st quarter).

The above information is self explanatory and to be filled appropriately.


Block 1: New smear positive cases only
Total number of
registered new
sputum positive
patients
(1)

Sputum at the end of IP


(2 months)
(2)
Negative

Positive

N.A.*

Sputum at the end of extended IP


(3 months)
(3)
Negative

Positive

N.A.*

*Not available / Sputum examination not done.

Column 1: Total number of patients registered in the quarter being assessed for
conversion is entered in this column (refer table above).
Column 2: Results of the sputum examination conducted at the end of two months (IP)

among new smear positive patients are reported as negative or positive or NA as the
case may be, under the sub-columns. Patients who are not subjected to sputum
examination or whose sputum results are not available for any reason are entered under
the column NA. The above information on the follow up of sputum examination results are
to be picked out from the relevant pages of the TB register pertaining to the quarter to be
reported.

Patients whose sputum results were positive in column 2 and whose intensive
phase was extended by one month are subjected to follow up sputum examination at the

Column 3:

15

Training Course for Program Manager


end of third month. Only results of these patients will be entered under the sub-columns
negative, positive and NA as the case may be.
Block 2: Previously treated cases (excluding others)
Total number of Previously
treated sputum - positive cases
(excluding others)
(1)

Sputum at the end of IP (3 months)


(2)
Negative

Positive

N.A. *

*Not available / Sputum examination not done.

Column 1: Total number of patients registered as relapse, treatment after default and

treatment failure in the quarter being assessed for conversion are entered in this column
(refer table above).

Column 2: Results of the sputum examination conducted at the end of intensive phase
{three months among previously treated smear positive patients (excluding others)} are
reported as negative / positive / NA as the case may be in the table above. Patients who
are not subjected to sputum examination or whose sputum results are not available are
entered under the column NA. The above information on the follow up of sputum
examination results are to be extracted from the relevant pages of the TB register
pertaining to the quarter being assessed.
The basis of calculation of sputum conversion rate:
The conversion rate among new smear positive cases is arrived through proportion of
total number of patients converted to smear negative at the end of 2nd and 3rd month out of
total sputum positive patients registered for treatment in the specific quarter. For example,
If out of the 100 new smear positive patients registered for treatment in the 1st quarter, 85
have become negative at the end of two months and 10 have become negative at the end
of three months, the sputum conversion rate is the cumulative of 85 and 10 i.e., 95 out of
100 = 95%.
The conversion rate among previously treated smear positive cases is arrived through
proportion of total number of patients converted to smear negative at the end of intensive
phase (3rd month) out of total previously treated sputum positive patients registered
(relapse, TAD and failures) for treatment in the specific quarter.
The benefit of arriving at conversion at the end of the extended intensive phase is
applicable only for new cases and not for previously treated cases.
Points to remember

Ensure that proper cohort is selected for assessment of sputum conversion.


It is a pre-requisite that the TB register should be up to date with reference to the
results of the follow up sputum examination for the eligible patients before report on
sputum conversion is prepared.
Patients whose follow-up results were not available at the end of 2/3 months for any
reason like interruption of treatment, death etc., should not be excluded from the
denominator i.e. total number of TB patients assessed in column 1.
16

Training Course for Program Manager

Patients included under sub - column NA at the end of two months of Intensive
Phase should not be reflected again under the sub - column meant for Sputum
results of the positive patients at 3 months
All new and previously treated smear positive patients registered in the particular
quarter must be included in this report.
Sputum conversion of the patients classified as Others under previously treated
cases is not considered in this report.

EXERCISE 3
In Mandya district, the number of New smear-positive patients started on treatment regimen
for new cases was 88. After two months of IP, 61 patients converted to smear-negative, 4
remained smear-positive and 23 did not have their sputum smear examination done. After
the extended IP, the 4 cases which remained smear-positive had their sputum examined
and all had converted to smear-negative.
1.
2.
3.

What is the sputum conversion rate at the end of IP (2 months)?


What is the sputum conversion rate at the end of the extended IP (3 months)?
How many patients did not have sputum smear examinations done at the end of IP and
extended IP, and what are the possible reasons for this?

Use the format given below:


Total number of
new sputum
positive patients
(1)

Sputum at the end of IP


(2 months)
(2)
Negative

Positive

N.A.*

*Not available / Sputum examination not done.

17

Sputum at the end of extended IP


(3 months)
(3)
Negative

Positive

N.A.*

Training Course for Program Manager

EXERCISE 4
Complete the Quarterly Report on Sputum Conversion on the next page using the five
pages in the Tuberculosis Register in Exercise Workbook E3. Use the worksheet provided
below.
Revised National Tuberculosis Control Programme
WORKSHEET
Quarterly Report on Sputum Conversion
Review every page of the TB Register for the quarter being reported on. Ensure that all available
sputum results have been entered into the register. Put a tally mark(/) in the appropriate cell below
and give the totals in the reporting format provided. Every Sputum Positive new, relapse, failure
and treatment after default cases registered must be entered in this report. Only pulmonary
sputum positive tuberculosis cases are included in this report.
One tally mark (/) is put for every case. Four tally marks are placed successively (////). When the
fifth case is recorded, the four tally marks already put in are crossed (-). In this way, each such
group represents five cases. This method of tally marking facilitates counting.

Block 1
Total number of
registered new
sputum positive
patients
(1)

Sputum at the end of IP


(2 months)
(2)
Negative

Positive

N.A.*

Sputum at the end of extended IP


(3 months)
(3)
Negative

Positive

N.A.*

Block 2
Total number Previously treated
of sputum -positive cases
registered (excluding others)
(1)

Sputum at the end of IP (3 months)


(2)
Negative

* N.A.: Not available / Sputum Examination not done.

18

Positive

N.A. *

Training Course for Program Manager


REVISED NATIONAL TUBERCULOSIS CONTROL PROGRAMME

Quarterly Report of Sputum Conversion

(New and Previously Treated cases Registered 4-6 Months Earlier)

Patients Registered during


quarter of 200

Name of area:
.
Code No. ____________________

Name of reporter: _____________________


Signature:___________________________________
Date of completion of this form:
Complete this proforma for sputum smear-positive patients. The total no should be the
same as in the Quarterly Report on Case finding for New and Previously treated Cases of
Tuberculosis.

Block 1
Total number of
registered new
sputum positive
patients
(1)

Sputum at the end of IP


(2 months)
(2)
Negative

Positive

N.A.*

Sputum at the end of extended IP


(3 months)
(3)
Negative

Positive

N.A.*

Block 2
Total number of Previously
treated sputum -positive cases
registered (excluding Others)
(1)

Sputum at the end of IP (3 months)


(2)
Negative

Positive

N.A. *

* N.A.: Not available / Sputum Examination not done.

Analysis of the quarterly report on sputum conversion


It is to be ensured that number of sputum positive patients (New and Previously
treated cases) reported in sputum conversion report matches with the number
reported in the case finding report for the same quarterly cohort
19

Training Course for Program Manager


Table 2: Sputum Conversion Indicators and possible responses to problems:
Expected

Indicator

Possible Actions

Conversion
rate is more
than 90% of
new smearpositive
patients at the
end of 3
months

Less than
85% of
New smearpositive
patients
become
sputum
smearnegative at 3
months

In the TUs with low sputum conversion rate, all PHIs should
be intensively supervised to identify whether:
1. Follow up sputum examination is not done in large
number of patients, then
Ensure that:
All MO PHI and staff ensure timely follow up sputum
examination of every patient under treatment.
Sputum cups are made available to all DOT providers with
clear instruction on the dose when the cups need to be
provided to the patients for follow up.
Patients who interrupt treatment, die or transferred out are
minimized.
2. Many patients remain sputum positive, then
Ensure that:
Accurate history-taking regarding previous treatment for TB
from any source is elicited for proper categorization and
efficient treatment. It should be explained to patients that
only if they provide accurate information, the most effective
treatment can be given. Proper classification and
categorization of cases is a pre-requisite for efficient
treatment.
Sputum microscopy is of good quality. Slides of patients
who remained smear positive at the end of the intensive
phase should be reviewed.
Every dose of medication is observed during the intensive
phase of treatment. DOT Centre should be convenient to
the patient and treatment interrupters are promptly
retrieved back.
The quality of DOTS should be checked at the time of
supervision, including checking of entries in the Treatment
Cards with the drugs available in patient-wise boxes.

Quarterly report on treatment outcome


The long term goal of Revised National TB Control Programme is to decrease mortality and
morbidity due to tuberculosis. Early diagnosis and prompt treatment is the most effective
and reliable method of controlling tuberculosis and will cut the chain of transmission of
infection.

20

Training Course for Program Manager


The goal is achieved through the following objectives:
To achieve and maintain

A cure rate of at least 85% among newly detected smear-positive (infectious)


pulmonary tuberculosis cases
Case detection of at least 70% of the expected new smear positive PTB cases in a
community

It is important to know that enhancing case detection be attempted only after achieving and
maintaining 85% cure rate among new smear positive cases. The only means by which
85% or more cure rate can be achieved on a programme basis is by adopting the DOTS
strategy.
The cure rate achieved for new pulmonary smear-positive cases registered in the
Tuberculosis Register under DOTS is a useful indicator to evaluate the effectiveness of
chemotherapy in treating tuberculosis cases.
The smear-positive previously treated cases are also evaluated in a similar manner. Smearnegative pulmonary cases are evaluated separately. Smear-negative pulmonary cases that
have successfully completed their treatment and have not become smear positive during
the course of treatment are declared as treatment completed.
Findings of reports on treatment outcomes help in supervising services of health workers
and monitoring of the programme. Sharing the reports on the results of treatment with
health workers can help them understand how their efforts have improved the cure rate. If
the cure rate of 85% has been achieved, it will make them proud of the work they have
done and hence, motivate them to maintain it. Cure rates should not be calculated for
individual health facilities within TB Units. This is because the number of cases may be too
low to give correct information.
At the beginning of each quarter, the Quarterly Report on Treatment Outcome of
Tuberculosis Patients Registered 1315 Months earlier will be completed (Hereafter,
referred to as Quarterly Report on Treatment Outcome). It summarizes the results of
treatment of patients under DOTS who were registered in the Tuberculosis Register 1315
months earlier. It is the most important report in the routine reporting system of tuberculosis
cases with respect to outcome of their treatment.
This section of the module helps you in knowing how to complete this report. We will learn
how to obtain the information from the Tuberculosis Register, how to summarize the data
and to enter the data into the appropriate columns of the report. We will also learn how to
cross-check the number of cases on this form with data reported earlier in the Quarterly
Report on Case Finding.
For the purpose of preparing the quarterly report on treatment outcome, only the
cases put on DOTS regimen are evaluated .The cases put on Non-DOTS regimen
are not considered for this report.

21

Training Course for Program Manager

General information
Cohort of patients to be considered: In this report, outcome of patients registered in the
quarter during 13 15 months earlier will be assessed. This facilitates the patients put on
any category of treatment including those whose intensive phase is extended for one
month, to complete the entire period of treatment, sufficient time for collection and collation
of information and for updating the TB register. For example, Cohort of patients put on
regimen for previously treated patients (requiring maximum duration of treatment) during
the first quarter of 2010 (January March 2010) would have completed their treatment
including extension of intensive phase and missed doses by the first quarter of 2011
(January March 2011) and will become eligible for assessment of treatment outcome and
reporting in the first week of the second quarter 2011 (Refer table below).
Cohort of patients registered in the Quarter and the time of reporting
Registered
During

Reported in 1st week


of

1st Quarter 2010

2nd Quarter 2011

2nd Quarter 2010

3rd Quarter 2011

3rd Quarter 2010

4th Quarter 2011

4th Quarter 2010

1st Quarter 2012

Procedure for preparing of quarterly report on treatment outcome


General information reflecting:

Name of the area and code number (TB Unit) This is self explanatory
Name and signature of the reporter (MO-TC/ DTO/ STO) This is self explanatory
Date of completion of this form This is self explanatory

This report has three blocks labelled as A, B & C. Block 'A' contains information on
treatment outcome of new and previously treated cases, B contains information on the
treatment outcome of TB patients who are co-infected with HIV and C provides information
on the total number of HIV positive TB patients and number of patients who are provided
with CPT and ART.

22

Training Course for Program Manager


BLOCK A : Treatment outcomes

Patient
reported
during
quarter**
(a)

Treatment Outcome
(c)
Type of patient
(b)

NEW CASES
Smear Positive
NSP

Cured

Treatment
completed

Died

Treatment
Failure

Defaulted

Transferred
out

Switched
over to
MDR-TB
treatment
7

Total
number
evaluated
(sum of 1
7)
(d)

Total
Male

Female
Smear Negative
Extra pulmonary
Others
Total new cases
PREVIOUSLY
TREATED CASES
Smear Positive
Relapses
Smear Positive
Treatment Failure
Smear Positive TAD
Others
Total Previously
treated cases
* The Reporter is the Medical Officer responsible, not the person completing this form.
** Of these_____________ (number) were excluded from evaluation of treatment outcome (Annexe details with the hard copy).

Block 'A' provides information on the treatment outcome of new and previously treated
cases.
Column (a): This column provides information on the total number of different types of
patients reported in the relevant quarter selected for determination of the treatment
outcome. For example, the cohort of patients diagnosed and put on treatment in 1st quarter
of 2010 will be taken up for determination of treatment outcome in the first week of 2nd
quarter of 2011, so on and so forth with other types of cases also.
Column (b): Provides information on types of patients under the following two sub-heads
New cases- comprises smear positive, smear negative, extra pulmonary, others and total
new cases. Sex wise break up of new smear positive cases is also provided under this
column.
Previously treated cases comprises smear positive relapses, smear positive failures, smear
positive treatment after default, others and total of all previously treated cases.
Column (c): There are seven sub - columns for seven possible treatment outcomes
namely, cured, treatment completed, died, failure, defaulted, transferred out and switched
to MDR-TB Treatment Regimen. The relevant treatment outcome will be indicated against
the types of patients. It is pertinent to remember that patient will have only one treatment
outcome.
Column (d): This will reflect the total number of cases evaluated against each type of
cases registered.

23

Training Course for Program Manager


BLOCK B: TB treatment outcomes of HIV Positive TB Patients
Type of TB
cases

Total No.
known to
be HIV
infected

Treatment outcomes
Cured

Treatment
completed

Died

Treatment
Failure

Defaulted

Transferred
out

Switched
over to
MDR-TB
treatment

NSP
All TB
Cases

Block 'B' has got three columns. It deals with the treatment outcomes of the HIV positive TB
patients. This provides information on number of new smear positive cases and all TB
cases who are known to be HIV positive and their different treatment outcomes.
Block C: CPT and ART

Total No. of TB patients known


to be HIV infected

No. given CPT

No. given ART

Block 'C' furnishes information on total number of TB patients known to be HIV infected and
number of those who are on CPT and ART.
Indicators for linkage of HIV positive TB patients to CPT / ART HIV care
1.
2.

Proportion of HIV positive TB patients receiving CPT during TB treatment


Proportion of HIV positive TB patients receiving ART during TB treatment

EXERCISE 5
Next to the dates given below for the first week of a new quarter, write the months you
would report on in the Quarterly Report on Treatment Outcome.
Date of reporting

Report on patients registered in the months


of

1 April 2010
1 July 2010
1 October 2010
1 January 2011
1 April 2011

EXERCISE 6
Using the worksheets on the following pages, complete the Quarterly Report on Treatment
outcome for the five pages of the Tuberculosis Register in Exercise Workbook E3. The
Quarterly Report on Treatment outcome follows the worksheets. Separate worksheets have
been provided for completing block A (two worksheets), block B and C (one worksheet
24

Training Course for Program Manager


each). After completing the worksheet, page wise, transfer the data to the appropriate block
/ cells in the quarterly report on treatment outcome.
Complete the top portion of the Quarterly Report on Treatment outcome as per the
following:

Name of area: Write the name of the sub-district/district.


Code No: Write the identification number for the sub-district/district.
Date of completion of this form: Write the day, month and year you are completing the
Quarterly Report.

Patients Registered during the quarter of 20.:


corresponding to 13 to 15 months earlier.

Write the quarter and the year

Name of Reporter : Write full name of the reporting Medical Officer.


Signature: Give the complete signature.
BLOCK A: Worksheet for quarterly report on treatment outcome (new cases)
Treatment outcome
Type of
patient

Page
No.

1
2
Smear
positive
cases

3
4
5

Sex

Cured

Treatment
completed

Died

Treatment
Failure

Defaulted

Transferred
out

Switched
over to
MDR-TB
treatment

Total
number
evaluated

M
F
M
F
M
F
M
F
M
F

1
Smear
negative
cases

2
3
4
5
1

Extra
pulmonary

2
3
4
5
1
2

Others

3
4
5

Total

*One tally mark (/) is put for every case. Four tally marks are placed successively (////). When a fifth case is to
be recorded the four tally marks already put in are crossed (////). Such a group represents five cases. This
method of tally marking facilitates counting.

25

Training Course for Program Manager


BLOCK A: Worksheet for quarterly report on treatment outcome (previously treated
cases)
Treatment outcome
Type of
patient

Page
No.

Smear
Positive
relapses

1
2
3
4
5

Smear
Positive
Treatment
failure

1
2
3
4
5

Smear
Positive TAD

1
2
3
4
5

Others

1
2
3
4
5

Cured

Treatment
completed

Died

Treatment
Failure

Defaulted

Transferred
out

Switched
over to
MDR-TB
treatment

Total
number
evaluated

Total

BLOCK B: Worksheet for treatment outcome for HIV positive TB patients

Type of TB
cases

NSP

All TB
Cases

Page
No.
1
2
3
4
5
1
2
3
4
5

Total
No.
known
to be
HIV
infected

Treatment outcomes
Cured

Treatment
completed

Died

Treatment
Failure

Defaulted

Transferred
out

Switched
over to
MDR-TB
treatment

BLOCK C : Worksheet for CPT and ART for HIV positive TB patients
Page No.

1
2
3
4
5
Total
# During TB treatment

Total No. of TB patients


known to be HIV
infected

No. given CPT#

26

No. given ART#

Male
Female

Total

Smear Negative
Extra pulmonary
Others
Total new cases
PREVIOUSLY TREATED CASES
Smear Positive relapses
Smear Positive Treatment failure
Smear Positive Treatment after
Default
Others
Total Previously treated cases

NEW CASES
Smear Positive
NSP

Type of patient

Treatment
completed
2

Died
4

Treatment
Failure
5

Defaulted

NSP
All TB Cases

Type of TB
cases

Total No.
known to
be HIV
infected

Cured

Treatment
completed

Treatment outcomes

Died

Treatment
Failure

BLOCK B: TB treatment outcomes of HIV Positive TB Patients

Defaulted

Switched over
to MDR-TB
treatment

Switched
over to MDRTB treatment
7

# During TB treatment

Total No. of
TB patients
known to be
HIV infected

No. give
CPT#

No.
given
ART#

Total number
evaluated
(sum of 1 7)

BLOCK C : CPT and ART

Transferred
out

Signature:

Name of Reporter: __* ______________

Transferred
out

* The Reporter is the medical Officer responsible not the person completing this form.
** Of these_____________ (number) were excluded from evaluation of treatment outcome (Annexe details with the hard copy).

Patient
reported
during
quarter**
Cured

quarter of __________

Date of completion of this form __________

BLOCK A : Treatment outcomes

Patients registered during ____________

Name of area_______________ No. _____

(Tuberculosis patients registered 13 15 months earlier)

Quarterly Report on Treatment Outcome

REVISED NATIONAL TUBERCULOSIS CONTROL PROGRAMME

Training Course for Program Manager

Procedure for preparing & reviewing Quarterly report on Treatment outcome


Source of information for preparing quarterly report on treatment outcome:

TB Register
Previous quarterly Report on case finding of the quarter selected for determination of
treatment outcome (i.e., patients registered 13-15 months earlier)

Completion of the top portion of the quarterly report on treatment outcome:


General information like name and code number of the TB Unit, name of the person
responsible for reporting, date of preparation of the report etc., are to be filled up and are
self explanatory.
Selection of the cohort of patients for determining treatment outcome:
For the compilation of the quarterly report on treatment outcome for the current quarter,
previous quarterly report on case findings pertaining to the patients registered 13 to 15
months earlier period has to be reviewed. eg. For compilation of the quarterly report on the
treatment outcome at the beginning of the 1st quarter 2010, i.e., 1st week of January 2010,
previous quarterly report on case findings & pages of the TB register pertaining to
the patients registered 13 to 15 months period earlier i.e., October December 2008
have to be reviewed.
Procedure for completion of the first column of the table in report on treatment
outcome:
The number of different types of cases diagnosed (sex-wise only for new smear positive)
are determined by looking into the appropriate previous report on case finding (as
mentioned above) and filled in column 1 against each types mentioned in column 2 of the
report on treatment outcome being prepared.
The pages pertaining to the quarter in the TB register having the summary of the treatment
outcome of TB patients is to be reviewed. This summary is arrived at after reviewing the
treatment outcome column of individual patients. The sample of the summary is reproduced
below:
Summary for treatment outcome:
Type of
cases
NSP

M
F

Treatment outcome
Cured Treatment Failure Defaulted Died Transferred
completed
out

NSN
NEP
New Others
Relapse
TAD
Treatment
Failure
Previously
treated
others

28

Switched to MDR-TB
Treatment regimen

Training Course for Program Manager


The different outcome of all new smear positive cases, sex-wise are arrived by adding all
such similar outcomes from all the pages pertaining to that quarter and filled in the row
against the type of cases mentioned in column 2. Similar procedure is followed for all the
cases mentioned in column 2 of the quarterly report on treatment outcome except for
gender-wise determination of the treatment outcome. As smear negative and extra
pulmonary cases cannot have the treatment outcome as cured, the corresponding area is
shaded grey.
The total number evaluated is arrived by adding all the types of treatment outcome
mentioned against each type of cases in column 2 of the quarterly report on treatment
outcome.
Generally, the number in the column 4 i.e., total number of patients evaluated should tally
with the number under patient registered during the quarter in column 1 of the quarterly
report on treatment outcome. If number evaluated is less than the number registered, this
may be evaluated individually and reason for the same be mentioned in the appropriate
space provided.

TB Treatment outcome of HIV positive TB patients


Block B: In this section, treatment outcome of HIV infected TB patients are reported.
Treatment outcome of patients who are reported as HIV positive is recorded against new
smear positive and all TB cases (including NSP) separately. The total number of TB
patients and new smear positive cases who are tested HIV positive before or during
diagnosis & treatment is recorded against them in column 2 and their outcomes in column
3. A sample of the Block 'B' of the quarterly report on treatment outcome is reproduced
below:
Type of
TB case

Total No.
known to
be HIV
infected

Treatment outcomes
Cure

Treatment
Completed

Died

Treatment
failure

Default

Transfer
out

Switched
over to
MDR-TB
Regimen

NSP
All TB
Cases

Block C: In this block, total number of TB patients who are HIV positive and number of
such patients put on CPT and / or ART is reported. This information has to be extracted
from individual patients, registered in the TB register.
Total No. of TB patients
known to be HIV infected

No. given CPT#

No. given ART#

# During TB Treatment

The proportion of HIV positive TB patients receiving CPT and/or ART shows the efficacy of
the programme to provide HIV care for the TB patients.
Points to remember

The number in the column 1 of the quarterly report on treatment outcome should
match with the total number in the corresponding report on case finding for each
type of cases
If for any reason, any of the patients registered is excluded from the evaluation, it
should be substantiated with recorded evidences.
29

Training Course for Program Manager

The summary at the bottom on the right hand side of the TB register should be
updated periodically. This will facilitate generation of quarterly report on treatment
outcome.

Analysis of quarterly report on treatment outcome


If the cure rate is <85%, among new smear positive cases, the performance is reviewed.
Such TUs / districts need intense supervisory visits.
Review of reasons for low cure rate

Discussion with health workers and their supervisors on the practice of administering
treatment and providing health education may be helpful in improving the cure rates. It is
to be ensured that health workers directly observe the drug intake by patients, especially
in the intensive phase. During the continuation phase, the first dose of every week
should be directly observed and the empty blister pack checked for the remaining doses
before giving medicines for the next week. Proper health education need to be imparted
to the patients on the importance of taking DOTS.

Interaction with patients should ensure that they understand their treatment regimens
and they need to take directly observed treatment. In addition, whether they have been
categorized properly based on past history of anti-TB treatment needs to be confirmed.

Review of TB Register for any errors in tallying or classifications of patients.

Discussion with the District TB Officer, Medical officer in-charge of health facilities and
MOs for arriving at reasons for low cure rate and remedial actions to be taken.

The table on the following page summarizes some possible causes of high rates of deaths,
failures, defaulters and transferred out cases leading to poor cure rates. (This is only
illustrative and not an exhaustive list.)

30

Training Course for Program Manager


Table 3: Treatment Outcome Indicators and possible solution to problems
Quarterly
Report
Expected:
Cure rate for
New smearpositive cases
is 85% or more

Expected:
Less than 3%
of New smearpositive
patients are
given the
outcome as
Treatment
completed.

Indicator

Possible Actions

Cure rate of
New smearpositive
patients
is less than
80%

Ensure that:
Visit to centres with low cure rates for discussion with
staff and patients to find out the reasons for low cure rate
and possible solutions.
It is to be ensured that elicitation of accurate history is
taking place at all levels. Patients must be asked
carefully about any prior treatment for tuberculosis taken
from any source. It should be explained to patients that
only if they provide accurate information, the most
effective treatment can be given. If previously treated
patients are not given the regimen for previously treated
cases, they may not respond well to treatment.
It is to be ensured that case definitions are applied
correctly. Any smear-positive patient treated for more
than one month in the past, with default of more than two
months, should receive the previously treated regimen.
It is to be ensured that every dose of medication is
observed during the intensive phase of treatment, and at
least one dose per week in the continuation phase.
Return of empty blister packs during weekly collection of
drugs should be insisted on. DOT centres should be
convenient for the patient.
It may be ascertained that health workers are
administering DOT as per guidelines.
Follow-up sputum smear examinations are done
according to guidelines.

Cure rate of
New smearpositive new
patients is
more than
95%.

Report is checked for accuracy. It is to be ensured that


results of treatment are correctly recorded and reported.
All diagnosed smear-positive patients started on
treatment should be registered.

New smearPositive
patients who
are reported
as treatment
completed is
more than 3%

Follow-up sputum examinations are done as per


guidelines and these are tracked carefully at all
treatment units.
Medical Officers and other health staff are sensitized
about the importance of follow-up sputum examinations.
Patients who have recently completed treatment are to
be located and their sputum samples obtained for
examination.

31

Training Course for Program Manager


Expected:
Less than 5%
of New
smear-positive
patients
die during
treatment

New smearpositive
patients who
die during
treatment is
more than 5%

Every dose of medication is observed during the


intensive phase of treatment, and at least one dose per
week in the continuation phase. DOT centres should be
convenient to the patient.
Records of patients who have died needs to be reviewed
to determine the reasons.
Attempt should be made for early diagnosis and prompt
treatment if it is found that seriously ill TB patients are
attending the health institutions.
The other reasons for high death rate could be comorbid conditions eg. HIV infection, Diabetes Mellitus
etc. which should be addressed appropriately.

Expected:
Failure: Less
than 4%
of New smearpositive
patients
continue to be
smear-positive
at 5 months or
more

New
smear-positive
patients
who fail
treatment is
more than 4%

It is to be ensured that elicitation of accurate history is


taking place at all levels. Patients must be asked
carefully about prior treatment for tuberculosis from any
source. It should be explained to patients that only if they
provide accurate information can the most effective
treatment be given. If previously treated patients are not
given the retreatment regimen, they may not respond
well to treatment.
It is to be ensured that categorization, is done properly.
Any smear-positive patient treated for more than one
month in the past, with default of more than two months,
should receive the previously treated regimen.
Every dose of medication is observed during the
intensive phase of treatment and at least one dose per
week in the continuation phase. Return of empty blister
packs during weekly collection of drugs in the
continuation phase should be insisted on. DOT centres
should be convenient to the patient.
It is to be ascertained that health workers are dispensing
medication properly as per guidelines.
It is to be ensured that drugs are of acceptable quality,
stored in appropriate conditions and are used before
their expiry.
In spite of all the above measures if the failure rate
remains higher than 5%, evaluation of the level of
primary drug resistance in the community should be
undertaken.

32

Training Course for Program Manager


Expected
Default rate is
less than
5%

Default rate of
smearpositive new
patients is
more than 5%

Directly observed treatment is given to patients in the


intensive phase and at least one dose per week is
directly observed during the continuation phase.
Practice of retrieval of treatment interrupters should be
meticulously followed by all health care providers i.e.
DOTS provider, PHI staff and supervisory staff at TU and
district level.
Visit to centres reporting high default rates. Interview of
staff and patients to determine the efforts made to
retrieve defaulting patients, the reasons for default and
possible solutions.
Patient history is carefully ascertained, including the
address. A visit to patients home should be made to
verify address prior to initiation of treatment and
landmarks near the house should be recorded in the
Treatment Card. Services should be convenient to the
patient in terms of distance, time and attitude of staff.
During the visit to the house for verification of address,
the name, address and telephone number of a contact
person in the event the patient defaults, is recorded.

Expected:
Transferred
out is less than
3%

Patients who
are
Transferred
out is more
than 5%

Ensure that:
Transfer out can be a way of disguising default. Patients
should be categorized as Transferred out only if they
have been given a Transfer Form to be taken to the
facility where they are transferred. The feedback of
results of follow up sputum examinations and treatment
outcome are reviewed.

Apart from these it is very important to analyse the cure rates, default rates, death rates and
failure rates of previously treated patients (relapses, failures and TAD) to study the
differences and trend of these various outcome indicators.

Report on Programme management and logistics


The following programme management and logistics reports are prepared at different
levels:

Monthly report on programme management and logistics PHI level


Quarterly report on programme management and logistics TU level
Quarterly report on programme management and logistics District level
Quarterly report on programme management and logistics State level

This report is generated on a monthly basis at PHIs and on quarterly basis at TU, district
and state level. The monthly PHI reports are consolidated on quarterly basis at the TU
level. The quarterly TU level reports are further consolidated at District & in turn at the State
Level. This report facilitates monitoring of logistics and other management activities
involved in successful implementation of TB control activities.

33

Training Course for Program Manager

PHI level monthly reports on programme management and logistics


All PHIs are required to complete this report on a monthly basis in the format provided. This
has the following sections:
a.
b.
c.
d.
e.
f.
g.
h.
i.
j.

General information
Medications - Stock of drugs & requirement
Supervisory activities
IEC/ACSM
Referral activity
Microscopy activity
Treatment initiation
MDR TB case finding activity
Consumables and laboratory requirements to be furnished by DMC.
Equipments

This report is to be prepared after physical verification of stock on the last working day of
the month by the MO of the PHI with the assistance of the concerned PHI staff. The report
has to be sent to the CDHO/CDMO with a copy to the TB unit on or before the fifth of next
month. A copy of the report is marked to the DTO for monitoring. The copies sent to the TU
level is used for monitoring as well as preparation of quarterly report on programme
management and logistics for the TU level.
General information: Details such as name of the PHI, TU, district, month and year of
report are to be recorded under this section.
Medications:
This section has to be filled up by all the PHIs. The information regarding the stock at the
beginning of the month, stock received & consumed during the month, stock at the end of
the month and stock requested have to be arrived at. This is done by reviewing the stock
register maintained for the drug boxes and actual physical stock available. The same
procedure is applicable even for loose drugs and streptomycin injections. The tables
mentioned below are self explanatory and have to be filled up accurately by the person
responsible for maintenance of the drug boxes and DOT administration at the PHI.

34

Training Course for Program Manager


REVISED NATIONAL TUBERCULOSIS CONTROL PROGRAMME
Monthly Report on Programme Management and Logistics
Peripheral Health Institution Level

Note:
1. All PHCs/ CHCs/ referral hospitals/ major hospitals/ specialty clinics/ TB hospitals/ Medical colleges to
submit their monthly reports in this format.
2.
PHIs without DMCs have to fill only the relevant details on page 2.
Name of Peripheral Health Institution: _______________________________________________________
TU: ______________________

District: ____________________

Month: ______________________

Year: ______________________

Medications
Adult Patient Wise Boxes
Stock on first
day of month
(a)

Item (PWB)

Stock received
during month
(b)

Patients
initiated on
treatment
(c)

Regimen for
New patients
(NT)

Stock on last
day of month
(d)=a+b-c

Quantity
Requested (e)=
(c X 2) d

Regimen for
previously
treated patients
(PT)

Prolongation Pouches and Inj SM


Item

Stock on
first day of
month
(a)

Stock
received
during
month
(b)

Consumption
during month
(c)

Stock on last
day of month
(d) =(a+b)-c

Quantity Requested
(e) =(cX2) d

Prolongation
pouches (Pouches
each with 12 blister
strips)
Streptomycin 0.75 g
(vials)

RNTCP loose drugs


Item

INH 300mg
INH 100mg
Rifampicin
150 mg
Ethambutol
800 mg

Unit of
measurement
Tablets
Tablets
Capsules

Stock on
first day of
month
(a)

Stock
received
during month
(b)

Tablets

35

Patients
initiated on
treatment
(c)

Stock on last
day of month
d=(a+b)-c
(d)

Quantity
Requested
e=(cx2)-d
(e)

Training Course for Program Manager


Supervisory activities:
Number of visits made to the PHI in the reporting month by DTO/MO-DTC, MO-TC, STS
and STLS are to be entered here. Visits undertaken by DOTS Plus & TB-HIV Supervisors
are also filled wherever these activities are being undertaken.
Supervisory activities:
Supervisory Visit by

nd

DTO/2
MO-DTC

MO-TC

DOTS Plus & TBHIV Supervisor

STS

STLS

Number of visits in last 1 month

IEC/ACSM:
Number of TB patient provider meetings and community meetings held in the reporting
month is to be entered here. (Refer to the section on ACSM in module 6)
IEC:

Number of TB Patient Provider meetings held


Number of Community meetings held

Referral activity: This has to be filled up by PHIs referring TB suspects to the DMCs for
sputum examination. This information will be obtained from the OPD register/records
maintained at PHI.
a) The number of new adult out patients attending the health institution is to be
recorded.
b) The total number of TB suspects (out of new adult out-patients mentioned above)
referred for sputum examination has to be mentioned in this section.
Referral Activity (To be filled in by all PHIs from OPD Register)
a.

Number of new adult outpatient visits

b.

Out of (a), number of TB suspects referred for sputum examination

Microscopy activity: This section has to be filled up by PHIs which are Designated
Microscopy Centres. Laboratory register is the source of information. The following
information is recorded in this section:
c) The number of TB suspects examined for diagnosis (including the suspects
referred from PHIs other than DMC linked to this DMC).
d) The number found smear positive among the above patients (d)
e) The number of TB suspects subjected to repeat sputum examination for diagnosis
f) The number found smear positive among repeat examination ('f' out of 'e')
g) Total number of smear positive cases diagnosed (d + f)
Microscopy Activity (To be filled in by only PHIs which are DMCs from Laboratory Register)
c.

Number of TB suspects whose sputum was examined for diagnosis

d.

Out of (c), number of sputum smear positive patients diagnosed

e.

Number of TB suspects subjected to repeat sputum examination for diagnosis

f.

Out of (e), number of sputum smear positive patients diagnosed

g.

Total number of sputum smear positive patients diagnosed (d + f)

36

Training Course for Program Manager


Treatment initiation
This section has to be filled up by Designated Microscopy Centers only. Information has to
be obtained from the remarks column of the laboratory register and referral for treatment
register. This can be verified with reference to treatment cards in the health institution. The
following information has to be entered in this section:
a) Number of smear positives cases (out of
b) Number of smear positives cases (out of
c) Number of smear positives cases (out of
within the districts.
d) Number of smear positives cases (out of
district.

g) put on DOTS
g) put on RNTCP Non-DOTS
g) referred for treatment to other TUs
g) referred for treatment outside the

Treatment Initiation (To be filled in by only PHIs which are DMCs from Laboratory Register and
Referral for Treatment Register)
h.

Of the smear-positive patients diagnosed (g), number put on DOTS

i.

Of the number of smear-positive patients diagnosed (g), number put on RNTCP NonDOTS (ND1 and ND2)

Of the smear-positive patients diagnosed (g), the number referred for treatment to
other TUs within the district

k.

Of the smear-positive patients diagnosed (g), the number referred for treatment
outside the district

MDR TB case finding activity


This data comes from the laboratory register at DMC.
MDR-TB case finding activity (To be filled in by PHIs which are only DMCs from Laboratory
Register)
Number of MDR-TB suspects identified

Consumables and Laboratory requirements: This has to be filled by PHIs which are
DMCs. Information regarding sputum containers has to be filled by all PHIs (even by PHIs
which are not DMCs and have been supplied with sputum containers). Laboratory Stock
registers maintained for consumables will be used to record the information in the table
which is self explanatory. Universal containers for C&DST are to be entered only if the DMC
has stock of it.

37

Training Course for Program Manager


Laboratory Consumables (To be filled in by only PHIs which are DMCs)
Item

Unit of
Measurement

Sputum
containers*

Nos.

Universal
containers for
C & DST

Nos

Slides

Nos.

Carbol Fuchsin
(1% solution)

Litres

Methylene Blue
(0.1% solution)

Litres

Sulphuric Acid
(25% solution)

Litres

Phenolic
solution (for
disinfection~40% pure
solution)

Litres

Immersion oil/
Liquid Paraffin
(Heavy)

mL

Methylated
Spirit

Litres

Stock on
first day of
the Month

Stock
received
during the
Month

Consumption
during the
Month

Stock on
last day of
the Month

Quantity
requested

* PHIs that are not DMCs, but have been supplied with sputum containers, should complete this row.

Equipments: This information has to be provided by PHIs which are DMCs. The position
regarding the number of microscopes available, irrespective of whether it is supplied under
RNTCP or other programmes and their functional status is recorded in this block.
Equipment in place (To be filled in by only PHIs which are DMCs)
Item

Number in
place

In working
condition

Binocular microscopes
Name of officer reporting (in Capital Letters) :

Signature:

Date:

Quarterly report on programme management and logistics - Tuberculosis Unit


(TU) level
The information reported in the monthly PHI level report is consolidated for preparing
quarterly TU report. In addition, the TU report includes information on supervisory
activities, and quality of DOTS implementation, The TU situated at the DTC will also submit
a quarterly report like all other TUs.
38

Training Course for Program Manager


Basic Information:
The number of DMCs in the TU under public sector, private sector and NGOs are to be
reported. The number of sputum collection centers, DOT centers, providers under public
sector, private sector, NGOs and community volunteers need to be reported.
The number of monthly PHI reports expected and received in the quarter are reported in the
beginning of the report.
Supervisory Activities:
The number of institutions visited by MO-TC, STS and STLS in a quarter is reported.
Although health unit may be visited more than once during the quarter, it is to be reported
as a single visit. The stipulated supervisory schedule is given in the module on supervision
& monitoring.
Referral and Microscopy Activities:
The information contained in these sections is the same as that given in the PHI Level
report. The figures given here must cover the information from all PHIs and DMCs under
the TU, including the microscopy centre of the TU consolidated for all three months of the
quarter.
In referral activities the number and percentage of PHIs reporting more than 2% of TB
suspects is to be entered.
Treatment Initiation:
This part of the report is compiled from the monthly PHI Level reports. Care should be
taken to avoid duplication of cases while doing the consolidation. One of the key
responsibilities of the STS is to ensure that every smear-positive patient who is diagnosed
is either started on treatment, or is promptly referred to another area where the patient
usually resides and will receive treatment.

Example:
Referral, microscopy and treatment activities of all PHIs including microscopy centres under
a TU during one quarter is furnished below:
Referral Activities
a.

Number (%) of PHIs referring >2% of new adult OPD patients for
sputum examination

4 out of 16
(25%)

Microscopy Activities
b.

Number of TB suspects whose sputum was examined for diagnosis

2250

c.

Out of (b), number of smear-positive patients diagnosed

215

d.

Number of TB suspects subjected to repeat sputum examination


for diagnosis

150

e.

Out of (d), number of sputum smear-positive patients diagnosed

15

f.

Total number of sputum smear-positive patients diagnosed (c + e)

230

39

Training Course for Program Manager


Treatment Initiation
g.

Out of the smear-positive patients diagnosed (f), number put on DOTS within
the TU

200

h.

Out of the number of smear-positive patients diagnosed (f), number put on


RNTCP Non-DOTS within the TU

12

i.

Out of the smear-positive patients diagnosed (f), the number referred for
treatment to other TUs within the district

05

Out of the smear-positive patients diagnosed (f), the number referred for
treatment outside the district

05

In the example, there were 10 smear-positive patients who are residents of areas outside
the TU. It may also be seen that 8 smear-positive patients [(f) (g+h+i+j)] who have neither
been referred for treatment outside TU area nor put on treatment under RNTCP. It is the
responsibility of the MOTC, STS and STLS to put them under treatment through the
concerned PHIs as soon as possible.
The DTO will ensure through TU level staff that all patients referred between TUs within the
district are put on treatment and reported appropriately.
MDR-TB case finding activity:
It is a consolidation of the PHI monthly report

Quality of DOTS implementation:


Quality of DOTS implementation is assessed by following indicators which are reported in
this section
a. Whether the all smear-positive cases are started on DOTS within seven days of
diagnosis?
This information is taken from the TB register from the columns date of start of
treatment and date of pretreatment sputum examination. The cases included should
be from the same cohort which have been included in the case finding report
b. Whether all smear-positive cases started on DOTS are registered within one
month
This information is taken from the TB register from the columns date of starting
treatment and date of registration; The cases included should be from the same
cohort which have been included in the case finding report
c. Whether all cured smear-positive cases had end of sputum examination done
within a week of the last dose.
This information is taken from the TB register from the columns date of last follow up
smear examination and date of treatment outcome; These cases should be from the
same quarterly cohort which have been included in the report of treatment outcome.
d. What is the number and proportion of TB patients (all forms) registered in the
quarter receiving DOT through a community DOT provider.
This information can be obtained from TB register after making a remark in the remark
column if the patient is getting DOT from a community volunteer. The cases included
should be from the same cohort which have been included in the case finding report.
40

Training Course for Program Manager


Medications, Consumables and, Equipments
The sections on Medications, Consumables, and Equipment are in the same format as
that of the PHI Level report. However, in the medications section, Regimen for MDR and
pediatric patient wise boxes are added. Note the formula for number requested for
Regimen for MDR drugs is with a reserve stock for one quarter.
These sections must include all PHIs in the area of the TU, and TU itself. However, the
columns on stock on first day of quarter and stock on last day of quarter should include
the stocks at TU drug stores in addition to those reported by PHIs. If the TU drug store
is receiving drugs from DTC for onward distribution to PHIs, the column on stock
received during quarter should include the receipts from DTC into the TU drugstore as
well as the drugs that may have been supplied to any PHI directly (bypassing the TU
drugstore) during the quarter. In rare circumstances, a TU may be asked to transfer
drugs or other lab consumables to other TU. This transfer should always be routed
through the district.
The stock on first day of quarter in the current quarters report should match with the stock
on last day of quarter in the previous quarters report.
Staff of the TU should complete a PHI Level report for the specific institution where the TU
is located, and then combine this information with that from all PHIs in the TU area.
Equipment in place
In addition to microscope, the number of two wheelers are to be reported, including the
number in working condition. Availability of vehicle for MOTC also need to be reported.

Quarterly report on programme management and logistics District level


District level Quarterly Report on Programme Management and Logistics is compiled by
1. Consolidation of information from the TU level Quarterly Report on Programme
Management and Logistics of:

Referral Activities
Microscopy Activities
Quality of DOTS implementation
Consumption of Medications and Consumables
Information on equipments at TB Units
MDR TB suspects identified

2. Consolidation of information from TU levels along with additional information from


district head quarter of:

Basic RNTCP Services


Information about Treatment Initiation
Medications
Consumables
Staff position
Equipment in place
IEC/ACSM activities
41

Training Course for Program Manager


3. Incorporation of information only from the district level of:

Supervisory activities by staff of DTC


Staff position and training of staff at periphery
Initial Defaulters in the section of Treatment Initiation
Number of MDR-TB suspects from whom sputum was collected and transported.
EQA
TB-HIV Activities
Stock transferred in, reconstitution of boxes during the quarter and stock transferred
out in the section of Medication
Equipment in place at DTC
Participation of Medical Colleges and TB Hospitals
NGOs/ Private Sector/other sector participation in RNTCP
Financial Management

1. Basic RNTCP Services:


The information on the number of DMCs and TUs in the public sector, private sector and
NGOs, number of sputum collection centres and DOT centres/providers are included in
the beginning of the report itself. This is a consolidation of the TU reports with the
exception of number of TUs
Some of the sections in the district level Report on Programme Management and
Logistics are described in details below:
2. Supervisory activities by staff of DTC
The number of institutions visited by DTO, MO-DTC and DOTS-Plus and TB-HIV
supervisor in a quarter is reported. Although health unit may be visited more than once
during the quarter, it is to be reported as a single visit. The stipulated supervisory
schedule is given in the module on supervision.
3. Referral activities
These activities are consolidated from the TU reports
4. Microscopy activities
These activities are consolidated from the TU reports0
5. Treatment initiation
The number of smear positive patients diagnosed and put on DOTS within the district,
number put on RNTCP, Non-DOTS and number referred for treatment outside the
district are compiled by consolidating the corresponding information from the TU reports.
Besides, the information on initiation of treatment for patients who are referred for
treatment outside TU within the district is to be obtained at the district level during the
monthly/quarterly meeting with the TU level staff and included along with the number of
patients initiated on treatment as mentioned above
Every attempt should be made to put all these referred patients on treatment. If
information regarding treatment of such referred patients cannot be obtained or learnt to
have not initiated on RNTCP regimen (DOTS / Non DOTS), these patients are included
as Initial Defaulters. The DTO has to find out the reasons for the initial default and make
attempts to reduce them.
42

Training Course for Program Manager


Initial defaulters
Information regarding Initial Defaulters is compiled only at the district level.
An Initial defaulter is a patient

Who is diagnosed as sputum smear-positive case as recorded in the RNTCP Lab


register

But has not been placed on either RNTCP DOTS treatment regimen or RNTCP nonDOTS treatment regimen and

Has not been referred for treatment outside the district.

6. MDR-TB case finding activity


Number of MDR-TB suspects identified is obtained by consolidation of TU reports. The
number of MDR TB suspects from whom sputum was collected and transported to the
lab for DST is taken from the Culture and DST referral register which is available at
DTCs of districts implementing MDR-TB management under RNTCP.
7. Quality of DOTS Implementation
This information has to be consolidated from the quarterly reports on programme
management and logistics from TUs.
8. TB/HIV Collaborative activities
In this section information about the number of TB-HIV meetings and district
coordination meeting are reported. Only meeting with approved and circulated minutes
are to be included.
9. EQA: Random Re- checking of Routine Slides at DTC
Number and percentage of DMCs with high false results (HFN and/or HFP) and number
and percentage of DMCs with only HFP results are reported. Note that this EQA data is
a cumulative one starting from January and reported till the previous quarter. Example
in the 2nd quarter 20010 PMR report, we will have EQA information of January to March
2010 only, while in the report of 1st quarter 2010, we could have EQA information from
January to Dec 2009. The data is compiled after analysis of monthly Annexure E of EQA
(Refer Mod-2).
Example:
District X has 10 DMCs (named DMC A to J).
Quarter
1st Quarter
2nd Quarter
3rd Quarter

4th quarter

Performance of DMCs
Only DMC C has High False Results

How to Report
Number (%) of DMCs having High
False Results: 1/10 (10%)
DMC B and DMC E have High False Number (%) of DMCs having High
Results
False Results: 3(30%)
DMC C has High False Results
Number (%) of DMCs having High
False Results: 3(30%)
DMC C has already been included in
1st quarter so not counted again
No DMC has High False Results
Number (%) of DMCs having High
False Results: 3(30%)

43

Training Course for Program Manager


10. Staff position and Training
In this table information about different cadres of staff, sanctioned positions, staff in
place and their training status is reported. This information will be available at district
level and need updating regularly. Under the column total in place and trained, include
the total number of staff in each category who are currently in place and are trained in
RNTCP. Since every RNTCP training in the district happens with the knowledge and
approval of DTO, the training records must be maintained at DTC by the DTO. These
records should be used to fill up the column on number of staff trained/ retrained during
the reporting period.
The information on the staffing of general health staff cadres and NACP staff need to
be obtained from the office of the CMO/CDHO of the district and the District Nodal
officer of NACP respectively.
11. Medications
The information on drugs for adults and children, both first and second line, are to be
reported in this section. Column on consumption is obtained by consolidation of TU
reports. The remaining columns are to be filled after taking into consideration the
consolidated TU reports and physical stock verification at DTC drug store, transfer
in/out between district and reconstitution done at district. Any drug with risk of expiry
should be reported.
12. Laboratory Consumables
The stock position of laboratory consumables is reported under this head here.
Universal containers for C & DST are to be reported by those districts implementing
MDR-TB management.
13. Equipments in place
In this section all listed equipments and their working condition is reported. Information
regarding vehicle for DTO and status of AMC for binocular microscopes is also
reported.
14. PPM-DOTS
14.1

The number of Medical Colleges and TB Hospitals in the government and private
sectors are reported in this section. The number of these institutions having an
RNTCP facility is reported separately. The Medical Colleges having an RNTCP
facility are usually provided with some minimum staff on contractual basis. The
details of such staff appointed in the Medical Colleges are also to be reported in
this section.

14.2

The number of NGOs/PPs engaged (signed and unsigned) in each of the


identified 11 schemes has to be reported in the relevant columns. In case the
NGO/PP is collaborating in more than one scheme, it will be counted separately
for each of those schemes. For example if an NGO is participating in ACSM,
DMC and adherence schemes, this NGO will be counted in all the three
schemes and will be totaled as three collaborations.

14.3 In the table for other sector involvement, the number present in the district and
number implementing RNTCP is reported. In order to obtain the number of such
institutions in the district, the DTO needs to Consult the relevant authorities, e.g.
Railways, ESI, Home department for prisons, Corporate sector management etc.
44

Training Course for Program Manager


15. IEC /ACSM
The number of patients-provider group interaction meetings and community level
meetings in the district during the quarter are reported in this section after consolidation
of the TU report. Additional information on activities pertaining to schools, PRIs, PPs,
NGOs and outdoor publicity needs to be reported from relevant records at DTC.
16. Financial Management
Under this section, write the last month/year in which contractual staff have been paid
their salaries and POL. Period up to which payments to all eligible NGOs/PPs was
made under the signed scheme is to be reported as month/year. Period up to which
payments made to all eligible Community DOT providers is also to be reported as
month/year

Quarterly report on programme management and logistics - State level


This report is prepared by collating the information from the district reports and additional
information available at STC, STDC, IRL, accredited DST labs and DOTS PLUS sites etc.
1.

Basic RNTCP services: Number of districts, STDCs, state drug stores, TB units,
DMCs, accredited DST labs, DOTS Plus centers/providers and sputum collection
centers existing under public / private sector, NGOs, Medical Colleges are
indicated in this section. Besides, the number of quarterly reports on case finding,
sputum conversion, treatment outcome, programme management and logistics,
report on infrastructure and activities of STDCs, state Task Force on medical
colleges, State Drug Stores, report on DOTS plus are enclosed along with this
report.

2.

Supervision and monitoring by the state: The supervision and monitoring


carried out by the state head quarters staff (STO, Dy. STO, MO at STC and/or
STDC officials) are reflected under this head. Similarly, the number of review
meetings of DTOs held in the quarter along with the minutes of the meeting is to be
reported. The information pertaining to analysis of the quarterly reports and
providing district feedback is also required to be reported. The number of districts in
which the internal evaluation conducted in the quarter and status of report send to
CTD is also reported here.

3.

Referral activities: Under this, the percentage of PHIs referring 2% and above of
adult outpatients for sputum examination is reported.

4.

Microscopy activities: Under this section number of TB suspects subjected for


sputum examination, number of smear positive patients diagnosed, number of TB
suspects referred for repeat sputum examination and cases diagnosed out of them
and total number of smear positive cases diagnosed are recorded.

5.

Treatment initiation: In this section, number of patients put on DOT within the
district, number of patients put on RNTCP non DOTS regimen and smear positive
patients diagnosed but referred for treatment outside the district are reported.

6.

MDR-TB case finding activity: Under this section, total number of MDR-TB
suspects identified and number of MDR-TB suspects from whom sputum was
collected and transported to diagnostic laboratory are indicated here.

7.

Quality of DOTS implementation: In this section, number and percentage of


smear positive patients started on RNTCP DOTS within seven days of diagnosis,
45

Training Course for Program Manager


number and percentage of smear positive patients registered within one month of
starting RNTCP DOTS, number and percentage of cured smear positive cases
having end of the sputum follow up examination within one week of the last dose
and number and percentage of patients receiving DOTS through community
volunteer are recorded.
8.

Quality assurance of sputum microscopy: The number of districts visited by IRL


team for the purpose of OSE and panel testing, percentage of STLS failing in the
panel testing, percentage DMCs with HF errors (HFN/HFP) till the previous quarter
and number of districts who have submitted EQA Annexure-E for all the three
months are reported under this section.

9.

Staff position at State level: Category of staff, number sanctioned , staff both
regular and contractual in place under RNTCP total in place and trained and
number trained and retrained are indicated under this section. The position and
training status of state head quarters staff are also to be reported. The complete
details of the state level training conducted by STDC and State TB Cell are also
reported in the relevant section.

10. Equipments in the state headquarters and STDC: Equipments available in the
state headquarters and STDC are reported with that of the districts. The working
condition of the equipments and the status of AMC of binocular microscopes and
IRL equipments are also reported. The status of state drug store, arrangement in
place for the transportation of drugs from the SDS to the districts are also reported
here.
11. Medication: The details of patient wise drug boxes meant for new and previously
treated cases. Information on prolongation pouches and injection SM, pediatric
drugs, and RNTCP loose and second line drugs are indicated under this section.
12. The TB-HIV collaboration activities: Under this heading whether co-ordination
committee meeting is held or not. If yes, minutes of the meeting are attached or
not, number of TB-HIV TWG meeting held during the quarter and information on
receipt of ICTC reports from SACS are indicated.
13. Participation of medical colleges and TB hospitals: Under section the number
of medical colleges and TB hospitals both government and private participating in
RNTCP are indicated. Besides, staff provided on contractual basis by the
programme is also indicated. In addition, information on NGOs and private
practitioners participating in RNTCP, the nature of scheme adopted by them are
also furnished. Involvement of other sections like ESI, railways, CGHS etc., are
also recorded in this section.
14. IEC/ACSM activities: Under this section the name of the activity and the number
implemented under each activity are furnished
15. Financial Management: In this section the following information are recorded.

The latest month and year for which all RNTCP contractual staff at the state
have been paid remuneration is reported as month/year.

The latest month and year for which all RNTCP contractual staff of all the
districts have been paid remuneration is reported as month/year.

The latest month and year for which all RNTCP contractual staff of all the
districts have been paid vehicle maintenance/POL is reported as month/year.
46

Training Course for Program Manager

Period for which NGOs/PPs with signed schemes were paid as per MOU in all
districts is to be reported as month/year.

Period up to which payments to all eligible community DOT providers has


been made in all the districts.

47

Training Course for Program Manager

Indicators & assessment of trend in the performance of the programme


management and logistics
Calculation of programme indicators from Quarterly report on programme
Management and Logistics
Indicator

Description

Calculation

Numerator: Total number of TB suspects


TB
suspects The number of TB suspects undergone
examination rate
sputum examination per lakh population per examine in the quarter/year
Denominator:
Mid-year population in
quarter/year
lakhs.
Ratio of the number of suspects examined
to the number of smear positive cases
diagnosed. This is an indicator reflecting
the efforts in smear positive case detection

Numerator: Total number of suspects


examined

%
of
smear Proportion of suspects who are diagnosed
positive
patients as smear positive cases and is expressed
amongst suspects as a percentage

Numerator: Total Number of smear


positive patients diagnosed X100
Denominator: Total number of suspects
examined

Percentage
of Proportion of patients who were diagnosed
initial defaulters
with smear positive TB in the lab register,
but have not been put on DOTS, non DOTS
or referred to other district for treatment
among all diagnosed smear positive cases
in the district.

Numerator: Number of diagnosed smear


positive patients who are not put on DOTS
or Non DOTS with in the districts or
referred out of the districts X100
Denominator: Total number of smear
positive diagnosed in the district

Percentage
of
smear
positive
cases
having
started on RNTCP
DOTS with in 7
days of diagnosis

One of the indicators for quality of DOT


implementation.
Proportion of smear
positive cases started on treatment with in 7
days of diagnosis

Numerator: smear positive cases having


started on RNTCP DOTS with in 7 days of
diagnosis X100
Denominator: Total number of smear
positive diagnosed in the district

Percentage
of
cured
smear
positive
cases
having
end
of
treatment follow-up
sputum done within
7 days of last dose

One of the indicators for quality of DOT


implementation. Proportion of cured smear
positive patients having end of treatment
follow up sputum done with in 7 days.

Numerator: Total Number of cured smear


positive patients having end of treatment
follow up sputum done with in 7 days of
last dose X100
Denominator: Total number of cured
sputum positive cases

Staff Position

Staff in position in the


Proportion of programme staff in position Numerator:
particular category
(category-wise)
Denominator: Sanctioned strength in the
category

Trained manpower

Proportion of staff trained in RNTCP Numerator: Staff trained in NTCP of a


particular category
(category-wise)
Denominator: Staff in position in the
respective category

Equipments

Proportion
condition

Suspects
examined
per
smear
positive
cases diagnosed

of

equipment

in

48

Denominator: Total number of Smear


positive patients diagnosed

Number of equipment in
working Numerator:
working condition
Denominator:
Total
number
of
equipment.

Training Course for Program Manager

Analysis of quarterly reports


Assessment of the quality of the reports
As the first step in the analysis of quarterly reports, an assessment should be conducted of
the quality of reports by examining the completeness, consistency and correctness of the
data.
Completeness: All reports that are expected from various levels needs to come in time. All
the rows and columns of the report should be filled with relevant data, whether it pertains to
the identification particulars of the district or programme data. No column should be left
blank unless warranted.
Consistency: Report is examined carefully and it is ensured that numbers are consistent
both internally with in the report and between relevant reports.
For example, in the
Quarterly Report on Case Finding, the total number of new smear-positive cases in Block-1
should tally with the total number of New smear-positive cases in Block-2. The
denominators for section in the PMR on quality of DOTS implementation should be
consistent with the corresponding cohorts of patients reported in the case finding and result
of treatment.
Correctness: Correctness of report means that the report is error free. The report is
examined for correctness in additions, compilation of numbers in various reports and
calculation/typographical errors. e.g, In the calculation of initial defaulters in PMR, it should
be checked in order to ensure that the patient put on DOTS, non-DOTS, patients referred
outside the districts and initial defaulters add up to the total smear positive cases
diagnosed.
Analysis of the data needs to be done by all programme managers at all levels. As a
general principle, program indicators need to be analyzed with respect to time, place and
person.
Analysis by time involves tracking of data and indicators over quarters and years. This will
give the trend in performance which needs to be analyzed for reasons and for planning
interventions. Any unexpected changes in the trend should prompt programme managers to
critically look at other related data and indicators in order to identify the cause and address
it.
Analysis by place implies comparison of data and indicators over geographical areas such
as TUs, Districts and States. Such comparisons should be aimed at identifying reasons for
geographical variations and sharing of best practices to improve poor performing TUs,
districts and states. For such comparisons maps are often used as a tool. An example of
mapping of key programme indicators by districts is there in the RNTCP National quarterly
performance report.
Analysis by person means description of data and indicators by person characteristics such
as age and sex. Calculation of age and sex specific notification rates is an example. Such
analysis helps in provision of equitable services and epidemiological assessment.

Case notification and detection rates and its analysis


Case notification rate is the number of tuberculosis cases registered in a specified time
period (per year) in unit population (per lakh) in a defined area (e.g. TU/district/state). This
depends on the extent to which patients utilize the health services. Consider a district with a
conversion rate of more than 90%, but a low case notification rate. This means that you are
providing effective treatment but are not reaching many cases.
49

Training Course for Program Manager


Case notification rate is expressed as number of cases per lakh per year.
For each state (or district), case notification rates can be calculated for all types of cases,
such as:

New pulmonary smear-positive

New pulmonary smear-negative

Relapses

Previously treated

Extra-pulmonary

Notification rate of smear positive case is one of the important indicators of


performance as they are responsible for spread of infection in the community. These
are:

New pulmonary smear-positive cases

Relapses

Other smear-positive previously treated cases

Trends in case notification rates over a period of time also should be reviewed. Annualized
case notification rate is calculated by multiplying the number of cases registered in a
quarter by 4 and dividing by the mid-year population in lakhs.
Case detection rate: It is the proportion of cases detected out of the estimated cases in
the district or state. New smear-positive case detection rate for a year, is calculated by
dividing the number of New smear-positive cases registered during the year by the
estimated incidence of smear positive cases for that population and multiplying it by
hundred. This is calculated by dividing annualized/annual NSP case notification rate
per lakh population by the estimated NSP cases per lakh population per year. For the
national level the estimated NSP case notification is 75/lakh population per year as
per the 2003 estimate. At least 70% of the expected new smear positive cases are to be
detected and placed on treatment, under RNTCP, as per the objectives of programme
For example, fifty (50) new smear positive cases have been detected per lakh per year in a
particular district out of 75 estimated. Thus the case detection rate works out to 50/75 x 100
= 66%
While analyzing the case notification rates, give special attention to the denominator, i.e.
the population. If the population given is not correct, then the rates may not reflect the
reality. Again it is not appropriate to calculate NSP case notification rate below the level of
districts as the small population denominator and other population characteristics will lead
to incorrect interpretations as far as case detection is concerned. In such circumstances, it
is better to use other indicators for case detection efforts like suspects examined per lakh
population, suspects examined per smear positive case detected, sputum positivity rate etc.
If the trend of new smear positive case notification rate is showing a decline in a district,
look at the trend of suspects examination rate, suspects examined per smear positive case
diagnosed, trend of proportion smear positive retreatment cases among all smear positive
cases, trend of proportion of new smear positive cases among all new pulmonary cases
etc. Process indicators like the proportion of medical officers and laboratory technicians in
place and trained, proportion of DMCs with high false errors etc need to be looked at and
linked to the programme performance indicator.
50

Training Course for Program Manager


Analysis of treatment outcomes; especially cure rates for new smear-positive cases
and smear positive previously treated cases.
The results of treatment for the group of cases registered in the quarter 1315 months
earlier (cohort analysis) will be analyzed in the current quarter. For calculating the outcome
indicators all cases registered are to be included in the denominator.
All cases started on treatment should be evaluated and the outcome recorded (into 7
outcome categories: cured, treatment completed, failure, died, defaulted, switched over to
MDR-TB treatment and transferred out). If there is no information on a patient (e.g. the
patient is reported to have moved out but was not transferred) the case should be classified
as defaulted.
The outcome indicators are expressed as a proportion of the number of patients registered.
Eg. Cure rate of new smear positive patients is calculated by dividing the number of NSP
cases cured by the number of NSP cases registered and to express this as a percentage
(multiply by 100). All types of outcomes are to be analyzed. If the cure rate is found to be
low, the proportions of other outcome indicators are to be looked into. Whether the low cure
rate is due to high default rate / death rate / failure rate or transfer out rate is to be
determined. If the denominator is small, the rates are likely to be fluctuating, e.g. if a district
is looking at the trend of failure rate among TAD cases, the rates may be very high in one
quarter while very low in another quarter, if the number of TAD registered is low. In such
situation it is better to look at the absolute numbers than rates. Treatment outcome for all
types of cases are to be analyzed.

Provision of feedback
Providing proper feedback will promote improvement in the accuracy and promptness of
reporting. Feedback indicates to the field personnel that the information they collect is used
and appreciated. It should be always remembered that, health workers efficiently
implementing the programme as per the guidelines should always be complimented. When
the analysis indicates problems with the data, the same is investigated and solutions sought
for remedial action.
Feedback - contents:

Comments on the completeness, consistency, correctness and timeliness of reports;

Comparisons of performance of different geographic areas (e.g. among states, or


among districts within a state).

Comments on trends of key indicators

Information about the programmes effectiveness based on findings of the report

Suggestions for improving the quality of the reports;

Information that might be helpful in solving problems;

Appreciation and compliments for the task accomplished and encouragement for
future progress.

51

Training Course for Program Manager


Methods of providing feedback
The methods of providing feedback include:

letters summarizing the findings of the report and appropriate summary tables and
charts on a quarterly basis;

periodic group meetings to encourage communication;

Summary of key indicators, possible causes, and possible responses to problems are given
in earlier pages of this module.

Time schedule for feedback


Last date for providing feedback on
quarterly reports from State to
Districts (copy to CTD)

Last date for providing feedback


on quarterly reports from CTD to
States

First

7th May (15th for large states)

30th June

Second

7th August (15th for large states)

30th September

Third

7th November (15th for large states)

31st December

Fourth

7th February (15th for large states)

31st March

Quarter

Person responsible for preparation of quarterly reports:


At TU level MO-TC is responsible with support from STS.
At district level DTO/Second MO is responsible
At state level STDC staff / designated officer if responsible for monitoring under the
supervision of STO

Records to be used for preparing the reports:


At PHI level TB treatment cards, physical stock of PWB, OPD register, Supervisory
register
At DMC level in addition to above TB lab register and stock register for Lab consumables.
At TU level-in addition to above TB register, Drug stock register, PHI monthly reports
At district level-TU level QPMR reports, Tour diary of DTO/supervision checklist,
supervision register, drug stock register, EQA -Annexure E, Referral for Culture and DST
register, Minutes of TB/HIV meetings, Records of staff position and training at DTC,
CMO/CDHO, referral register, line list o NGOs, PPs, other sectors, record of ACSM
activities and district financial records.
Electronic Programme surveillance system
The quarterly reports in RNTCP are entered at the district in the EPICENTRE software and
transmitted electronically to state and national level. For this purpose each district has
been provided with computer with necessary soft ware, internet connection and contractual
data entry operator. The EPICENTRE software allows for correct data entry with internal
checks, storage of data in a database, secured transmission of data, easy retrieval of data
and output for specific programme indicators and analysis including trend over
quarters/years and maps. This software is used at national and state level for summarising
52

Training Course for Program Manager


programme performance indicators by TU, district and state. These indicators are
published in the national/state quarterly/annual programme performance reports
Some Performance Indicators with formula
Indicator
Annualized Total Case
Notification Rate
Annualized New Smear Case
Notification Rate (ANSP CNR)
NSP CDR (%)
Proportion of smear positive
among new pulmonary TB
cases
Proportion of new EP cases
amoung all new cases
Proportion of S+ve previously
treated cases among all S+ve
cases
Sputum Conversion Rate of
NSP cases

Cure Rate of NSP Cases

Success rate of NSP Cases

TB Suspects examination
Rate
Suspects examined per smear
positive case diagnosed

Proportion of Initial Defaults


(%)

Formula
(Total Cases registered during the quarter X4)
Population in Lakhs
(Total New smear positive cases registered during the quarter
X4)
Population in Lakhs
ANSP CNR X 100
Estimated incidence of smear positive cases for that area
NSP X100
NSP+NSN
(From Block-1 of case finding report)
NEP X100
NSP+NSN+NEP+new Others
(From Block-1 of case finding report)
S+ve previously treated cases X 100
NSP+ S+ve previously treated cases
(From Block-1 of case finding report)
NSP cases converted at 2 months and 3 months X100
NSP cases registered during the quarter
(From Quarterly report on sputum conversion of new and
previously treated cases registered 4-6 months earlier)
NSP Cases Cured X100
NSP cases registered
(From Quarterly report on treatment outcome of new and
previously treated cases registered 13-15 months earlier)
(NSP Cases Cured + NSP Cases treatment completed) X100
NSP Cases Registered
(From Quarterly report on treatment outcome of new and
previously treated cases registered 13-15 months earlier)
TB suspects examined in the quarter/year
Population in Lakhs
(From Quarterly Report on Programme management)
TB Suspects examined
Smear positive cases diagnosed
(From Quarterly Report on Programme management)
(Total Number of smear positive cases diagnosed in the district (Number of smear positive cases started on DOTS/Non DOTS
with in the district + number of smear positive cases referred for
treatment out side the district)) X 100
Total Number of smear positive cases diagnosed in the district

53

Code No.# ____________

Name of area: ____________

Notes: Quarterly : 1st quarter January, February, March


2nd quarter April, May, June
3rd quarter July, August, September
4th quarter October, November, December

# Number

Block 2: New Smear Positive Pulmonary Tb cases only: from column above
Age
0 14
15 24
25- 34
35 44
Male
Female
Total

Male
Female
Total

Block 1: All new and previously treated patients registered in the quarter
New cases
New smear
New smear
New extra
Others
positive
negative
pulmonary TB
pulmonary TB pulmonary TB
0-14 Yrs
15 Yrs
Total

55 - 64

Treatment
Failures

65

Treatment
After Default

Total

Total

Others

Of (a)
Of all Registered TB cases,
Number known to be HIV
Number known to be tested for
Identification
the
infected
HIV before number
or duringofthe
TBarea.
treatment
(b)
(a)

Block 3: TB/HIV Collaboration

45 - 54

Relapse

Previously Treated Cases

Name of the reporter: ___________________________________ Signature: ____________________ Date of completion of this form

Patients registered during _____________


quarter of 200 _____

(New and Previously Treated Cases of Tuberculosis)

REVISED NATIONAL TUBERCULOSOS CONTROL PROGRAMME


Quarterly Report on case finding

Training Course for Program Manager

REVISED NATIONAL TUBERCULOSIS CONTROL PROGRAMME


Quarterly Report of Sputum Conversion
(New and Previously Treated cases Registered 4-6 Months Earlier)

Patients Registered during


quarter of 200 _

Name of area:
.
No. _____________________

Name of reporter: _____________________


Signature:___________________________________
Date of completion of this form:
Complete this proforma for sputum smear-positive patients. The total number should be the
same as in the Quarterly Report on New and Retreatment Cases of Tuberculosis.
Block 1
Total number of
new sputum
positive patients

Sputum at the end of IP


(2 months)
Negative

Positive

N.A.*

Sputum at the end of extended IP


(3 months)
Negative

Positive

N.A.*

Block 2
Total number of sputum -positive
Previously treated cases
(excluding others)

Sputum at the end of IP (3 months)


Negative

* N.A.: Not available / Sputum Examination not done.

55

Positive

N.A. *

Male
Female

Total

Smear Negative
Extra pulmonary
Others
Total new cases
PREVIOUSLY TREATED CASES
Smear Positive relapses
Smear Positive Treatment failure
Smear Positive Treatment after
Default
Others
Total Previously treated cases

NEW CASES
Smear Positive
NSP

Type of patient

Treatment
completed
2

Died
4

Treatment
Failure
5

Defaulted

NSP
All TB Cases

Type of TB
cases

Total No.
known to
be HIV
infected

Cured

Treatment
completed

Treatment outcomes

Died

Treatmen
t Failure

Defaulted

BLOCK B: TB treatment outcomes of HIV Positive TB Patients

Switched
over to MDRTB treatment

Transferred
out

Total
number
evaluated
(sum of 1
7)

# During TB treatment

No. given
CPT#

No. given
ART#

BLOCK C : CPT and ART

Switched
over to MDRTB treatment

Total No. of TB
patients known to
be HIV infected

Transferred
out

Signature:

Name of Reporter: __* ______________

* The Reporter is the medical Officer responsible not the person completing this form.
** Of these_____________ (number) were excluded from evaluation of treatment outcome (Annexe details with the hard copy).

Patient
reported
during
quarter**
Cured

quarter of __________

Date of completion of this form __________

BLOCK A : Treatment outcomes

Patients registered during ____________

Name of area_______________ No. _____

(Tuberculosis patients registered 13 15 months earlier)

REVISED NATIONAL TUBERCULOSOS CONTROL PROGRAMME


Quarterly Report on Treatment Outcome

Training Course for Program Manager


REVISED NATIONAL TUBERCULOSIS CONTROL PROGRAMME
Monthly Report on Programme Management, Logistics and Microscopy

Peripheral Health Institution Level


Note:
1. All PHCs/ CHCs/ referral hospitals/ major hospitals/ specialty clinics/ TB hospitals/ Medical colleges to
submit their monthly reports in this format.
2. PHIs without DMCs have to fill only the relevant details on page 2.
Name of Peripheral Health Institution: ________________________________________________
TU: ______________________

District: __________________

Month: ______________________

Year: __________________

Medications
Item (PWB)

Stock on first day


of month
(a)

Stock received
during month
(b)

Patients initiated
on treatment
(c)

Stock on last
day of month
(d)
=a+b-c

Quantity
Requested
(e)
= (c X 2) d

Regimen for
New patients
(NT)
Regimen for
previously
treated patients
(PT)

Adult Patient Wise Boxes

Prolongation Pouches and Inj SM


Item

Stock on
first day of
month
(a)

Stock
received
during
month
(b)

Consumption
during month
(c)

Stock on
last day of
month
(d)
=(a+b)-c

Quantity
Requested
(e)
=(cX2) d

Prolongation pouches
(Pouches each with 12
blister strips)
Streptomycin 0.75 g (vials)

RNTCP Loose Drugs


Item

Stock on
first day of
month
(a)

Stock
received
during
month
(b)

Tab INH 300 mg


Tab INH 100 mg
Cap Rifampicin 150 mg
Tab Ethambutol 800 mg

57

Consumption
during month
(c)

Stock on last
day of month
(d)
=(a+b)-c

Quantity
Requested
(e)
=(cX2)-d

Training Course for Program Manager


Supervisory activities:
nd

Supervisory Visit by

DTO/2
MO-DTC

MO-TC

DOTS Plus & TB-HIV


Supervisor

STS

STLS

Number of visits in last 1 month

IEC:
Number of TB Patient Provider meetings held
Number of Community meetings organized

Referral Activities (To be filled in by all PHIs from OPD Register)


a.

Number of new adult outpatient visits

b.

Out of (a), number of TB suspects referred for sputum examination

Microscopy Activities

(To be filled in by only PHIs which are a DMC from Laboratory Register)
c.

Number of TB suspects whose sputum was examined for diagnosis

d.

Out of (c), number of sputum smear positive patients diagnosed

e.

Number of TB suspects subjected to repeat sputum examination for diagnosis

f.

Out of (e), number of sputum smear positive patients diagnosed

g.

Total number of sputum smear positive patients diagnosed (d + f)

Treatment Initiation

(To be filled in by only PHIs which are a DMC from Laboratory Register and Referral for Treatment Register)

h.

Of the smear-positive patients diagnosed (g), number put on DOTS

i.

Of the number of smear-positive patients diagnosed (g), number put on RNTCP NonDOTS (ND1 and ND2)

Of the smear-positive patients diagnosed (g), the number referred for treatment to
other TUs within the district

k.

Of the smear-positive patients diagnosed (g), the number referred for treatment outside
the district

MDR-TB case finding activity

(To be filled in by only PHIs which are a DMC from Laboratory Register)
Number of MDR-TB suspects identified

Laboratory Consumables

(To be filled in by only PHIs which are a DMC)


Item
Sputum
containers*
Universal
containers for C &
DST
Slides
Carbol Fuchsin
(1% solution)

Unit of
Measurement
Nos.

Stock on first
day of Month

Stock received
during Month

Nos
Nos.
Litres

58

Consumption
during Month

Stock on last
day of Month

Quantity
requested

Training Course for Program Manager


Methylene Blue
(0.1% solution)
Sulphuric Acid
(25% solution)
Phenolic solution

Litres

Immersion oil/
Liquid Paraffin

mL

Methylated Spirit

Litres

(for disinfection-~40%
pure solution)

Litres
Litres

(Heavy)

* PHIs that are not a DMC, but have been supplied with sputum containers, should complete this row.

Equipment in place (To be filled in by only PHIs which are a DMC)


Item

Number in place

In working condition

Binocular microscopes

Name of officer reporting (in Capital Letters) :

Signature:

Date:

59

Training Course for Program Manager


REVISED NATIONAL TUBERCULOSIS CONTROL PROGRAMME
Quarterly Report on Programme Management and Logistics

Tuberculosis Unit Level (including Tuberculosis Unit at DTC)


Name of the TB Unit:

State: _________

Name of the District:

Quarter:

Year: ___________

Total population of the TB Unit (in numbers):

Basic information of the TU


Stake- holders

Public Sector
(including Govt. /
Corporation Medical
Colleges, Govt.
health dept., other
Govt. dept. and
PSUs)

Private Sector (Private


Medical College,
Medical Practitioner,
Private Clinics/Nursing
Homes and Corporate
sector)

NGOs

Community
Volunteers

Total

Number of DMCs
Number of Sputum
collection centres
Number of DOT
Centres/providers
Number of PHIs expected to submit monthly PHI reports
Number of PHIs that submitted monthly PHI reports for all 3 months in the quarter
The following reports are enclosed (Tick [] to indicate that the report is enclosed)

Quarterly Report on Case - Finding

Quarterly Report on Sputum Conversion

Quarterly Report on Results of Treatment

If any report is not enclosed, give reason ____________________________________________________

Supervisory activities (to be compiled from PHI reports and tour diaries)
Type of Unit

Number of these visited * during quarter by


MO-TC

Designated Microscopy Centres


DOT Centres/providers
Patients
* Write only the number of health facilities visited and not the number of times that they were visited.

Referral Activities
a.

Number (%) of PHIs referring > 2% of new adult out patients for sputum examination

Microscopy Activities
b.

Number of TB suspects whose sputum was examined for diagnosis

c.

Out of (b), number of sputum smear positive patients diagnosed

d.

Number of TB suspects subjected to repeat sputum examination for diagnosis

60

STS

STLS

Training Course for Program Manager


e.

Out of (d), number of sputum smear positive patients diagnosed

f.

Total number of sputum smear positive patients diagnosed (c + e)

Treatment Initiation
g.

Of the smear-positive patients diagnosed (f), number put on DOTS within the TU

h.

Of the number of smear-positive patients diagnosed (f), number put on RNTCP Non-DOTS (ND1
and ND2) within the TU

Of the smear-positive patients diagnosed (f), number referred for treatment to other TUs within the
district

j.

Of the smear-positive patients diagnosed (f), number referred for treatment outside the district

MDR-TB case finding activity


Number of MDR-TB suspects identified

Quality of DOTS implementation


1.

Number (%) of all Smear Positive patients started on RNTCP DOTS treatment within 7 days of
diagnosis (Information from TB Register)

2.

Number (%) of all Smear Positive patients registered within one month of starting RNTCP DOTS
treatment (Information from TB Register)

3.

Number (%) of all cured smear positive patients* having end of treatment follow-up sputum
examination done within one week of last dose (Information from TB Register)

4.

Number (%) of patients (all forms of TB) registered during the quarter receiving DOT through a
community volunteer (Information from TB Register)

* These cases should be from the same quarterly cohort which have been included in the report on Results of Treatment

Medications
Adult Patient Wise Boxes
Item

Unit of
Measurement

Regimen for
New
Patients
(Cat-I)

Boxes

Regimen for
Previously
treated
patients
(Cat-II)

Boxes

Stock on
first day of
Quarter

Stock received
during the
quarter

Patients
initiated on
treatment

Stock on last
day of Quarter
(a+b) (c)

Quantity
Requested
[(c/3) x 4] (d)

(a)

(b)

(c)

(d)

(e)

Prolongation Pouches and Inj SM


Item

Unit of
Measurement

Stock on first
day of Quarter

Stock
received
during the
quarter

Consumption
during the
quarter

Stock on
last day of
Quarter
(a+b) (c)

Quantity
Requested
[(c/3) x 4]
(d)

(a)

(b)

(c)

(d)

(e)

61

Training Course for Program Manager


Prolongation
pouches

Pouches each
with 12 blister
strips

Streptomycin 0.75 g

Vials

Paediatric drugs (Including drugs for Adult Patients <30kgs)


Item

Unit of Measurement

Paediatric PC 13

Boxes

Paediatric PC 14

Boxes

Paediatric PC 15

Pouches each with 12


blister strips

Paediatric PC 16

Pouches each with 12


blister strips

Stock on
first day of
quarter

Stock
received
during
quarter

Consumption
during
quarter

Stock on last
day of
quarter
(a+b) (c)

Quantity
Requested
[(c/3) x 4]
(d)

(a)

(b)

(c)

(d)

(e)

RNTCP Loose Drugs:


Item

Unit of
Measurement

INH 300 mg

Tablets

INH 100 mg

Tablets

Rifampicin 150 mg

Capsules

Ethambutol 800
mg

Tablets

Stock on
first day of
quarter

Stock
received
during the
quarter

Consumption
during
quarter

Stock on last
day of Quarter
(a+b) (c)

Quantity
Requested
[(c/3) x 4] (d)

(a)

(b)

(c)

(d)

(e)

MDR treatment regimen


Item

Unit of
measurement

IP ( 45 Kg Body wt )

PWB

IP ( > 45 Kg Body wt)

PWB

CP ( 45 Kg Body wt)

PWB

CP ( > 45 Kg Body
wt)
Na PAS for one
month in 3 boxes (100
gms each)

Stock on
first day
of the Qtr

Stock
received
during the
Qtr

Consumption
during the Qtr

Stock on
last day of
the Qtr
(a+b) c

Quantity
Requested
for TU
(c x 2) d

(a)

(b)

(c)

(d)

(f)

PWB
Carton of 3
boxes

Is there any drug at the risk of expiry*?


If yes attach details

Yes

No

62

Training Course for Program Manager


* Regimen for new cases-12 months; Regimen for previously treated -14 months; PC 13 & PC 14 - 12
months; MDR treatment regimen -6 months
Is there any expired drugs?
If yes attach details

Yes

No

Laboratory Consumables*
Item

Unit of
Measurement

Sputum containers

Nos.

Universal containers
for C & DST

Nos.

Slides

Nos.

Carbol Fuchsin (1%


solution)

Litres

Methylene Blue
(0.1% solution)

Litres

Sulphuric Acid (25%


solution)

Litres

Phenolic solution (for


disinfection-40%
pure solution)

Litres

Immersion Oil/
Liquid paraffin
(Heavy)

mL

Methylated Spirit

Litres

Stock on
first day
of Quarter

Stock received
during Quarter

Consumption
during
Quarter

Stock on last
day of Quarter

Quantity
requested

Equipment in place
Item

Number in place

Binocular microscopes
Two-wheeler

Vehicle for MO-TC: Jeep in working condition Hired vehicle None

IEC
Number of TB Patient Provider meetings held
Number of Community meetings organized

Name of Medical Officer Tuberculosis Control reporting (in Capital Letters):

Signature:

Date:

63

In working condition

Training Course for Program Manager

REVISED NATIONAL TUBERCULOSIS CONTROL PROGRAMME


Quarterly Report on Programme Management and Logistics

District Level
Name of the District:

State:

Total projected population of District/Reporting Unit (in numbers):

; Quarter:

Year: ____

NGOs

Community
Volunteers

1. Basic RNTCP services


Stake- holders

Public Sector
(including Govt. /
Corporation Medical
Colleges, Govt. health
dept., other Govt. dept.
and PSUs)

Private Sector (Private


Medical College,
Medical Practitioner,
Private Clinics/Nursing
Homes and Corporate
sector)

Total

Number of TB Units
Number of DMCs
Number of Sputum
collection centres
Number of DOT
Centres/providers
Number of PHIs expected to submit monthly PHI reports
Number of PHIs that submitted monthly PHI reports for all 3 months in the quarter

2. Supervisory activities by the Staff of the DTC


No. visited by

TU

DMC

Medical
College/ TB
Hospital

PHI (other
than DMC)

DOT
centres

DTO
MO-DTC
DOTS Plus and TB-HIV
Supervisor

No of RNTCP review meetings held during the quarter?

3. Referral Activities
a.

Number (%) of PHIs referring >2% of New Adult out patients for sputum examination

4. Microscopy Activities
b.

Number of chest symptomatic patients whose sputum was examined for diagnosis

c.

Out of (b), number of smear positive patients diagnosed

d.

Number of TB suspects subjected to repeat sputum examination for diagnosis

e.

Out of (d), number of sputum smear positive patients diagnosed

f.

Total number of sputum smear positive patients diagnosed (c + e)

64

Patients

ICTCs/ART
centers

Training Course for Program Manager


5. Treatment Initiation
g.
h.

Of the smear-positive patients diagnosed (f), number put on DOTS within the district
Of the number of smear-positive patients diagnosed (f), number put on RNTCP NonDOTS (ND1 and ND2) within the district
Of the smear-positive patients diagnosed (f), number referred for treatment outside the
district
Initial defaulters j = f (g+h+i)

i.
j.

6. MDR-TB case finding activity


Number of MDR-TB suspects identified
Number of MDR-TB suspects from whom sputum was collected and
transported to diagnostic lab

7. Quality of DOTS implementation


7.1.

Number (%) of all smear positive patients started on RNTCP DOTS treatment within 7
days of diagnosis (Information from TU PM report)

7.2. Number (%) of all smear positive patients registered within one month of starting RNTCP
DOTS treatment (Information from TU PM report)
7.3. Number (%) of all cured smear positive patients* having end of treatment follow-up
sputum examination done within one week of last dose (Information from TU PM report)
7.4. Number (%) of patients (all forms of TB) registered during the quarter receiving DOT
through a community volunteer (Information from TU PM report)
* These cases should be from the same quarterly cohort which have been included in the report on Results of Treatment

8. TB-HIV Collaborative activities [from the district records]


8.1. No. of District level meetings for TB/HIV held with NACP staff during the quarter
8.2. Was the Quarterly District Coordination Committee meeting held in the quarter?

YES / NO

9. EQA: Random blinded cross checking of routine slides at DTC


(from the district records)
Report on DMCs for the year
(Cumulative for the year [Jan Dec])

Number

Number of DMCs with HF results (HFN and/or HFP results)*


Number of DMCs with HF Positive results (HFP)*
*Till the end of the previous quarter

10. Staff Position and Training


In Place
Category of staff

Sanctioned

State Govt
Staff/staff from
other programmes

RNTCP Staff (from the district records)


District TB Officer
Second Medical
Officer of the DTC
Designated Medical
Officer (MO-TC) of
the TB Unit
DOTS Plus & TB-HIV
supervisor

65

Contractual
under RNTCP

Total in
place and
Trained

Number
trained/retrained
during reporting
period

Training Course for Program Manager


Senior Treatment
Supervisor (STS)
Senior Tuberculosis
Laboratory
Supervisor (STLS)
TB Health Visitor
DMC LT/
Microscopist
Data Entry Operator
General Health Staff (from records of the district)
Medical Officer (at
BPHC / PHC /
CHC/district
hospital/other)
Paramedical staff
including health
workers
DOT providers/
Community
Volunteers, including
ASHAs (or
equivalent)
NACP (from the district records)
ICTC Counsellors
District Supervisors
ART Medical Officers
NGO/PP/Medical College (from the district records)
Medical Officers
Paramedical Staff,
including LT and DOT
Providers

11. Medications
Adult Patient Wise Box
Item

Unit of
Measurement

Stock
on first
day of
Quarter

(a)
Regimen
for New
patients
(Cat-1)

Boxes

Regimen
for
Previously
Treated
(Cat-2)

Boxes

Stock
received
during
the
quarter

Stock
transferred
in

(b)

(c)

Reconstitution of
boxes
during
Quarter

Stock
Transferred
Out *

(d)

(e)

66

Patients
started
on
treatment

Stock on
last day
of
Quarter
(a+b+c+d)
(e+f)

(f)

(g)

Quantity
Requested

[(f/3) X 7]g
(h)

Training Course for Program Manager


Prolongation Pouches and Inj SM
Item

Unit of
Measurement

Stock
on first
day of
Quarter

Stock
received
during
the
quarter

(a)
Prolongation
Pouches

Pouches
each with
12 blister
strips

Streptomycin
0.75 g

Vials

Stock
transferred
in

Reconstitution during
quarter

Stock
Transferred
Out *

Consumption
during the
quarter

Stock on
last day
of
Quarter
(a+b+c+d)
(e+f)

(b)

(c)

(d)

(e)

Quantity
Requested

[(f/3) X 7]g

(f)

(g)

(h)

Consumption
during
quarter

Stock on
last day
of
Quarter

Quantity
Requested

Paediatric drugs (Including drugs for Adult Patients <30kgs)


Item

Unit of
Measurement

Stock
on first
day of
Quarter

Stock
received
during
the
quarter

(a)
Paediatric
PC 13

Boxes

Paediatric
PC 14

Boxes

Paediatric
PC 15

Pouches
each with
12 blister
strips

Paediatric
PC 16

Pouches
each with
12 blister
strips

Stock
transferred
in

Reconstitution
during the
Quarter

Stock
transferred
Out *

(a+b+c+d)
(e+f)

(b)

(c)

(d)

(e)

(f)

[(f/3) X 7]g

(g)

(h)

RNTCP Loose drugs


Item

Unit of
Measurement

INH 300 mg

Tablets

INH 100 mg

Tablets

Rifampicin
150mg

Capsules

Pyrazinamide
750 mg

Tablets

Ethambutol
800 mg

Tablets

Stock
on first
day of
Quarter

Stock
received
during
the
quarter

Stock
transferred
in

Stock
Transferred
Out *

Consumption
during
Quarter

Stock
on last
day of
Quarter
(a+b+c)
(d+e)

Quantity
Requested
[(e/3) X 7]-f

(a)

(b)

(c)

(d)

(e)

(f)

(g)

*Enclose copy of drug transfer-out form with the printed copy of the report

67

Training Course for Program Manager


Category IV drugs
Item

Unit of
measurement

IP ( 45 Kg Body wt )

PWB

IP ( > 45 Kg Body wt)

PWB

CP ( 45 Kg Body wt)

PWB

CP ( > 45 Kg Body
wt)
Na PAS for one
month in 3 boxes (100
gms each)

Stock on
first day
of the Qtr

Stock
received
during the
Qtr

Consumption
during the Qtr

Stock on
last day of
the Qtr
(a+b) c

Quantity
Requested
for DTC
(c x 2) d

(a)

(b)

(c)

(d)

(e)

PWB
Carton of 3
boxes

Is there any drug at the risk of expiry**?


If yes attach details

Yes

No

** Regimen for new cases -12 months; Regimen for previously treated cases -14 months; PC 13 & PC 14 - 12 months;
MDR treatment regimen -9 months
Have any drugs expired drugs during the quarter?
If yes attach details

Yes

No

12. Laboratory consumables


Item

Unit of
Measurement

Sputum containers

Nos.

Universal containers for Culture


& DST

Nos.

Slides

Nos.

Basic Fuchsin (powder)

Gms

Methylene Blue (powder)

Gms

Sulphuric Acid Conc (liquid)

Litres

Phenol (99.5% pure)( solid)

Gms

Phenolic solution (for


disinfection; ~40% pure)

Litres

Immersion oil/ Liquid Paraffin


(Heavy)

ml

Methylated Spirit

Litres

Stock on
first day of
Quarter

Stock received
during Quarter

Consumption
during
Quarter

Stock on
last day of
Quarter

13. Equipment in place


Item

Number in place

Source
(RNTCP / Others)

Binocular microscopes
Weighing Balance
Photocopier
Computer

68

Not in working condition and


since when

Training Course for Program Manager


Internet connection
Overhead projector
Fax machine
Two-wheeler

vehicle in working condition Hired vehicle None

Vehicle for DTO:

Is AMC Present for Binocular Microscopes: Yes/No

14. PPM-DOTS
14.1. Participation of Medical Colleges and TB Hospitals
(a) Nature of ownership
Health facility
Medical
Colleges
TB Hospitals

Government
With
Without
RNTCP
RNTCP
facility
facility

Private
With
Without
RNTCP
RNTCP
facility
facility

With
RNTCP
facility

Total

Without
RNTCP
facility

Staff provided on contractual basis to Medical Colleges


Category of Staff

Total number in the district

MO
LT
TBHV

14.2. Number of NGOs/ private practitioners participating in RNTCP during the quarter*:
ACSM

Sputum
collection

Sputum
Transport

DMC
(a)

RNTCP PPM Scheme


DMC LT Culture Adherence
(b)
& DST

Slum

TU

NGO
PPs
Total

14.3. Other sector involvement


Sector

Number in the district

ESI
Railways
CGHS
Prisons
Corporate hospitals
PSU/others (mining, shipping, defence)

69

Number implementing RNTCP

TBHIV

Total

Training Course for Program Manager


15. ACSM (IEC)
Activity

No. conducted

TB Patient Provider Meetings


Community Meetings
School based activities
Sensitizations: PRI / PPs/NGOs etc
Outdoor publicity : Local folk/mass media campaign/mela

16. Financial management


MM/YY

Financial Management
Latest month for which all RNTCP contractual staff has been paid remuneration
Latest month for which all RNTCP contractual staff has been paid Vehicle maintenance / POL
Period up to which payments to NGO/PPs under signed schemes have been made
Period up to which payments to eligible Community DOT Providers has been made

Name of District (Municipal) Tuberculosis Officer reporting (in Capital Letters).


Signature:

Date:

70

Training Course for Program Manager

REVISED NATIONAL TUBERCULOSIS CONTROL PROGRAMME


Quarterly Report on Programme Management and Logistics
State Level
Name of the State: ________________________

Quarter and year: __________

Name and address of STO: ____________________________________________________________


___________________________________________________________________________________

1. Basic RNTCP services


Stake- holders

Public Sector
(including Govt. /
Corporation Medical
Colleges, Govt.
health dept., other
Govt. dept. and
PSUs)

Private Sector (Private


Medical College,
Medical Practitioner,
Private Clinics/Nursing
Homes and Corporate
sector)

NGOs

Community
Volunteers

Total

Number of Districts
Number of STDCs
Number of State drug
stores
Number of TB Units
Number of DMCs
Number of RNTCP
accredited culture and
DST labs
Number of DOTS plus
sites
Number of DOT
Centres/providers
Number of Sputum
collection centres
The following reports are enclosed (Tick [] to indicate that report is enclosed)

Quarterly Report on Case Finding * :

Quarterly Report on Sputum Conversion* :

Quarterly Report on Results of Treatment* :

Quarterly Report on Programme Management and Logistics* :____)

Quarterly Report on Infrastructure and Activities of STDC:

Quarterly Report on State Task Force on Medical Colleges

Quarterly Report of State Drug Store

Quarterly Report on the DOTS-Plus

)
)

(Unit This would generally be the district, however in certain cases the district may have 2 or more separate reporting
units like Municipal Corporation and rural areas. Each reporting unit should be counted for reporting purpose)
*If any unit did not submit reports, list name(s), report(s), reason(s) and action taken ______________________________
_________________________________________________________________________________________________

71

Training Course for Program Manager


2. Supervision and monitoring by the State
Number of RNTCP districts visited during
the quarter (By STO, Dy STO, MO at STCS
and/or STDC officials)

Number of RNTCP districts not visited,


attach list of districts not visited with
reason/s

Review meeting of all DTOs of RNTCP Districts held this quarter?


Yes
No
If Yes: Is the approved minutes available
Yes
No
If No; reason/s ________________________________________________________
Was TU-wise analysis done and distributed to all districts?
If yes, has it been placed on the programme website?

Yes
Yes

No
No

Was individual district performance feedback provided to the districts?


If yes, has it been copied to Central TB Division?

Yes
Yes

No
No

Number of districts for which an internal evaluation was performed in the quarter:
Number of District Internal Evaluation reports sent to CTD in the quarter:

3. Referral Activities
a.

Number (%) of PHIs referring >2% of New Adult out patients for sputum
examination

4. Microscopy Activities
b.

Number of chest symptomatic patients whose sputum was examined for


diagnosis

c.

Out of (b), number of smear positive patients diagnosed

d.

Number of TB suspects subjected to repeat sputum examination for diagnosis

e.

Out of (d), number of sputum smear positive patients diagnosed

f.

Total number of sputum smear positive patients diagnosed (c+e)

5. Treatment Initiation
g.

Of the smear-positive patients diagnosed (f), number put on DOTS within the
district

h.

Of the number of smear-positive patients diagnosed (f), number put on RNTCP


Non-DOTS (ND1 and ND2) within the district

i.

Of the smear-positive patients diagnosed (f), number referred for treatment


outside the district

6. MDR-TB case finding activity


Number of MDR-TB suspects identified
Number of MDR-TB suspects from whom sputum was collected and transported to
diagnostic lab

7. Quality of DOTS implementation


7.1. Number (%) of all smear positive cases started on RNTCP DOTS treatment within 7 days
of diagnosis (Information from District PM report)
7.2. Number (%) of all smear positive cases registered within one month of starting RNTCP

72

Training Course for Program Manager


DOTS treatment (Information from District PM report)
7.3. Number (%) of cured all smear positive cases* having end of treatment follow-up sputum
examination done within one week of last dose (Information from District PM report)
7.4. Number (%) of patients (all forms of TB) registered during the quarter receiving DOT
through a community volunteer (Information from District PM report)
* These cases should be from the same quarterly cohort which have been included in the report on Results of Treatment

8. Quality assurance of sputum microscopy


Sl.
No.
1
2
3

Activity

Number during the


reporting quarter

Cumulative
number

No. of districts visited by IRL team for the purpose of OSE and
panel testing during the quarter and the year
No. (%) of STLS failing the panel testing
Number (%) of DMCs with High False Results (HFN and/or
HFP results) till the previous quarter and in the year (January
to December):
Number (%) of DMCs with High False Positive (HFP) Results
till the previous quarter and in the year (January to December):
Number of districts who have submitted of EQA annex-E for all
the 3 months of the previous quarter to IRL

4.
5.

9.1 Staff position at the state level


In Place
Category of staff

Sanctioned

State
Government
Staff/staff
from other
programmes

State TB Cell
STO
Deputy STO
MO State TB Cell
Epidemiologist
TB HIV co-ordinator
Urban TB Coordinator
IEC Officer
Accountant
Data entry operator
Secretarial Assistant
State TB Training and Demonstration Centre
STDC Director
IRL Microbiologist
STDC Medical
Officers
Epidemiologist

73

Contractual
under
RNTCP

Total in
place and
Trained

Number
trained/retrained
during reporting
period

Training Course for Program Manager


IRL LTs
DOTS Plus site
DOTS Plus site MO
DOTS Plus site
statistical Assistant
State drug stores
SDS Pharmacist

9.2. Staff position at the district level (All districts combined)


In Place
Category of staff

Sanctioned

State
Government
Staff/staff
from other
programmes

District Level Staff


District TB Officer
Second Medical Officer
of the DTC
Communication
facilitators
Designated Medical
Officer (MO-TC) of the
TB Unit
DOTS Plus and TB-HIV
Supervisors
Senior Treatment
Supervisor (STS)
Senior Tuberculosis
Laboratory Supervisor
(STLS)
TB Health Visitor
DMC LTs/ Microscopist
Data Entry Operators
Medical Officer (at
BPHC / PHC /
CHC/other)
Paramedical staff
including health workers
DOT
providers/Community
Volunteers including
ASHAs (or equivalent)*

74

Contractual
under
RNTCP

Total in
place and
Trained

Number
trained/retrained
during reporting
period

Training Course for Program Manager


9.3. Details of training activities held at STDC/State level during this quarter
Category of trainees
(specify if re-training)

No. of trainees
batch-wise

From (Date)

To (Date)

Duration (Days)

(a)
(b)
(c)
(d)
Total training days

10. Equipment in place


Item

Number in place
State HQ

STDC

All RNTCP
Districts

In working condition
State
HQ

STDC

All RNTCP
Districts

Binocular microscopes
X-ray machine of DTC
Photocopier
Fax machine
Computer
Internet connection
LCD projector
Overhead projector
Vehicles
Jeep / Four-Wheelers
10 seater bus
Two-wheeler
Is there an AMC in place for binocular microscopes?

Yes No

Is there an AMC in place for IRL equipment supplied by RNTCP?

Yes No

Any IRL equipment for culture and DST on solid media not working/not available

Yes No

If yes then attach details.


Has the state done the annual procurement of Culture and DST lab consumables for the current financial
year?
Yes No
State Drug Store Status
Arrangement in place for transport of drugs from SDS to districts
Contract at State level with a transport agency
Collection by individual districts using DTC vehicles
Any other (attach details)

75

Training Course for Program Manager


11. Medications
11.1. Adult Patient Wise Boxes
Item

Stock
on first
day of
Quarter

(a)

Stock
received
during
the
quarter

(b)

Stock
transferred
in

(c)

Reconstitution
of boxes
during
Quarter

(d)

Stock
Transferred
Out *

(e)

Patients
started
on
treatment

(f)

Stock on
last day
of
Quarter
(a+b+c+d)
(e+f)
(g)

Quantity
Requested

[(f/3) x 10]g
(h)

Regimen
for New
Patients
(Cat-1)
Regimen
for
Previously
treated0
Patients
(Cat-2)

11.2. Prolongation Pouches and Inj SM


Item

Stock
Stock
Stock
Reconstitution
Stock
Consumption Stock on
on first received transferred during Quarter Transferred
during
last day of
Out *
day of
during
in
Quarter
Quarter
Quarter
the
(a+b+c+d)
quarter
(e+f)
(a)

(b)

(c)

(d)

(e)

(f)

(g)

Quantity
Requested

[(f/3) x 10]-g

(h)

Prolongation
pouches each
with 12 blister
strips
Streptomycin
0.75 g (vials)

11.3. Paediatric drugs (Including drugs for Adult Patients <30kgs)


Item

Stock
Stock
Stock
ReconstituStock
Consump- Stock on
Quantity
on first received transferred tion during Transferred
tion
last day
Requested
in
Out *
day of during
Quarter
during
of
Quarter
the
Quarter
Quarter
quarter
(a+b+c+d)
[(f/3) X 10]-g
(e+f)
(a)

(b)

(c)

(d)

Paediatric PC
13 (Boxes)
Paediatric PC
14
(Boxes)

76

(e)

(f)

(g)

(h)

Training Course for Program Manager


Paediatric PC
15
(Pouches each
with 12 blister
strips)
Paediatric PC
16
(Pouches each
with 12 blister
strips)

11.4. RNTCP Loose Drugs


Item

Stock
on first
day of
Quarter

Stock
received
during
the
quarter

Stock
transferred
in

Stock
Transferred
Out *

Consumption
during
Quarter

Stock
on last
day of
Quarter
(a+b+c)
(d+ ef)

(a)

(b)

(c)

(d)

(e)

(f)

Quantity
Requested

[(e/3) X 10]-f

(g)

Tab INH 300 mg


Tab INH 100 mg
Cap Rifampicin 150 mg
Tab Pyrazinamide 750
mg
Tab Ethambutol 800 mg
* Enclose copy of drug transfer out form
% (and names) of districts having drug stocks for less than one month at the end of quarter (from Medications section of
District PM Report):

77

Patient
Wise
Boxes
(From
Compilation
of
District
PMR
Reports)
IP ( 45 Kg Body Weight Patient)
IP ( > 45 Kg Body Weight Patient)
CP ( 45 Kg Body Weight Patient)
CP ( > 45 Kg Body Weight Patient)
NA PAS containing drugs for 1
month in 3 small boxes

SODIUM PARA-AMINOSALICYLIC
ACID (NA PAS)

Loose Drugs (from SDS and DOTS


Plus Sites)
KANAMYCIN (Km) - 500 mg
KANAMYCIN (Km) - 750 mg
OFLOXACIN (Ofx) - 200 mg
LEVOFLOXACIN (Ofx) - 400 mg
CYCLOSERINE (Cs) -250 mg
ETHIONAMIDE (Eto) - 250 mg
PYRAZINAMIDE (Z) - 500 mg
PYRAZINAMIDE (Z) - 750 mg
ETHAMBUTOL(E) - 200 mg
ETHAMBUTOL(E) - 800 mg
PYRIDOXIN - 100 mg

Item

PWB
PWB
PWB
PWB
Carton
of
3
boxes

Vials
Vials
Caps
Caps
Tabs
Tabs
Tabs
Tabs
Tabs
Tabs
Tabs
Box of
100
gms

UOM

(a)

Stock
on
first day of
the Qtr (SDS
+ DOTS Plus
Site +DTCs)

Stock transferred In /
received during the
Qtr (From Suppliers +
returned
back
incomplete
IP/CP
boxes from DTCs)
(b)

(X)

Consumption during the


Qtr (Only at the DOTS
Plus Site+DTCs after
converting IP/CP boxes
as in (X) below into loose
drugs)
(c)
(d)

Transfer
Out
(From
SDS
only)

Note: For filling in information in Column ( c), the loose drugs in the IP/CP boxes as in (X) need to be accounted for purposes of compilation.

1
2
3
4
5

1
2
3
4
5
6
7
8
9
10
11
12

S.No.

11.5 RNTCP second line anti-TB drugs

(e)

Stock on last day


of the Qtr (SDS +
DOTS Plus Site +
DTCs)
E=(a+b)-(c+d)
(f)

Requirement/
Request
for
transfer
of
drugs

Training Course for Program Manager


12. TB-HIV collaborative activities
Whether state level TB-HIV coordination committee met during the quarter Yes/ No
If yes, are the approved minutes of the meeting available? Yes/No
No. of TB-HIV TWG meetings held during the quarter_____
Monthly ICTC reports from SACS received? Yes/No

13.1. Participation of Medical Colleges and TB Hospitals


(a) Nature of ownership
Government
With
Without
RNTCP
RNTCP
facility
facility

Health facility
Medical Colleges
TB Hospitals

Private
With
Without
RNTCP
RNTCP
facility
facility

With
RNTCP
facility

Total

Without
RNTCP
facility

(b) Staff provided on contractual basis to Medical Colleges


Category of Staff

Total number in the state

MO
LT
TBHV

13.2. NGOs participating in RNTCP

(signed as well as unsigned schemes) during the quarter*:


Number of NGOs/ private practitioners participating in RNTCP during the quarter*:
RNTCP PPM Scheme
ACSM
(IEC)

Sputum
collection

Sputum
Transport

DMC
(a)

DMC
(b)

LT

Culture
& DST

Adherence

Slum

TU

TBHIV

Total

NGO
PPs
Total

13.3. Other sector involvement


Sector

Number in the state

Number implementing RNTCP

ESI
Railways
CGHS
Prisons
Corporate hospitals
PSU/others (mining, shipping, defence)
(Attach list of NGOs and private sector institutions, which have started participating in any of the above schemes in the most
recent quarter including name, address, and scheme.)

79

Training Course for Program Manager


14. IEC / ACSM activities
Activity

No. Implemented

Patient Provider Meetings


Community Meetings
School based activities
Sensitizations: PRI / PPs/NGOs etc
Outdoor publicity : Local folk/mass media campaign/mela
Other activties (specify)

15. Financial management


Financial Management

MM/YYYY

Latest month for which all RNTCP contractual staff at the state level has been paid
remuneration
Latest month for which all RNTCP contractual staff in all districts have been paid their
remuneration
Latest month for which all RNTCP contractual staff in all districts have been paid
Vehicle maintenance / POL
Period up to which payments to NGO/PPs under signed schemes in all districts have
been made
Period up to which payment to the eligible Community DOT Providers has been made
in all the districts

Name of officer reporting (in Capital Letters with designation ): ______________________________

Signature: ____________________________________
Date: _________________________________

80

Table of Contents
Module - 6
Programme Management
Introduction ................................................................................................................................
Learning Objectives .....................................................................................................................
District & State Annual Action plan .............................................................................................
Annual Action plan format ..........................................................................................................
Training .......................................................................................................................................
Training Induction........................................................................................................................
Implementation of training plan .................................................................................................
Activity in ACSM ..........................................................................................................................
Social Mobalization .....................................................................................................................
Developing ACSM Annual action plan .........................................................................................
Engaging all care providers..........................................................................................................
PPM Providers .............................................................................................................................
Eligibility and grants ...................................................................................................................
Role of RNTCP ..............................................................................................................................
Role of NGO .................................................................................................................................
Involvement of Medical colleges in the RNTCP ...........................................................................
Financial management under RNTCP ..........................................................................................
National Rural Health Mission (NRHM) .......................................................................................

83
83
83
84
93
94
97
101
102
105
107
108
109
111
111
118
122
126

Training Course for Program Manager

MODULE 6

PROGRAMME MANAGEMENT
Introduction
Programme management comprises of planning, implementation and its
maintenance. Realistic planning is based on situational analysis of geographical and
demographic features and the available infrastructure. Implementation consists of provision
of trained staff, ensuring logistics in place and service delivery. The objectives are achieved
and maintained through recruitment and training of the required staff, maintaining logistics
in place, promotion of programme through advocacy and IEC activities and maintenance of
quality of services involving all the stake holders, supervision, monitoring, periodic
evaluation and appropriate corrective actions

Learning objectives: At the end of the module the participants will learn about various

aspects of programme management and be able to undertake the related activities.

1. District Annual Action Plan and State Annual Action Plan


2. Training
3. Implementation of Advocacy, Communication and Social Mobilization Activities
(ACSM)
4. Engaging all care providers
5. Involvement of Medical Colleges
6. Financial Management under RNTCP
7. National Rural Health Mission (NRHM)
8. RNTCP NACP Co ordination

1. District Annual Action Plan & State Annual Action Plan


DTOs and STO should undertake a SWOT ( S-Strenth,W-Weakness,O-Oppurtunity,TThreat) analysis (mentioned in Module 9 managerial skills for Program Managers ) of
the programme and prepare an annual report-cum-plan that may include the following:
1. Goal and objectives of the program with prioritization of issues and activities in the
district / state
2. Strengths and weaknesses of the program in the district (internal factors)
3. Opportunities and threats that exist in the district for the program (external factors)
4. Action plans and budgetary requirements for the next financial year
Actions plans and budgetary requirements: In order to take the corrective steps and to
achieve the desired level of performance, the DTO would have to plan activities, time
frame and finance for the next financial year. The budget in the District Annual Action
Plan is thus based on the improvement desired in the performance indicators and
activities planned to achieve the same.
The format of action plans and budgetary requirements includes:
1. Assessment of the current performance of RNTCP in the district
2. Determination of a feasible level of performance for the coming year
3. Determination of priority areas
4. Determination of activities under each priority area

83

Training Course for Program Manager


The format for preparation of District Annual Action Plan is as below:
ANNUAL ACTION PLAN FOR PROGRAMME PERFORMANCE &
BUDGET FOR THE YEAR
ST
1 APRIL 20____ TO 31ST MARCH 20_____
District __ _________________

State _________ ___

This action plan and budget have been approved by the DHS (District health society).
Signature of the DTO __________________________________
Name__________________________________ Designation ______________________
Section-A General Information about the District
1 Population (in lakh) please give projected population 20__
2 Urban population
3 Tribal population
4 Hilly population
5 Any other known groups of special population for specific
interventions
(e.g. nomadic, migrant, industrial workers, urban slums)
(These population statistics may be obtained from Census data / District Statistical Office)

ORGANIZATION OF SERVICES IN THE DISTRICT:


Does the district have a DTC____Y/N
S. No.

Name of the TU

Population (in
Lakhs)

Please indicate if the TU isGovt

1
2
3
4
5
6
7
8
9

DISTRICT

84

NGO

No. of MCs
Govt

NGO

Private

Training Course for Program Manager


RNTCP performance indicators:
Important: Please give the performance for the last 4 quarters i.e. July ___ to June ____

TB
Unit

Total
number
of
patients
put on
treatment

No of
new
smear
positive
cases
put on
treatment

Total case
notification
rate (per
lakh pop)

New
smear
positive
case
notification
rate (per
lakh p op)

Cure rate for


cases
detected in
the last 4
corresponding
quarters

Plan for the next year


NSP
Notification
rate(per
lakh pop) &
CDR (%)

Proportion of
TB patients
tested for HIV
Cure rate

No. of MDR
cases put on
treatment

Section B List Priority areas for achieving the objectives planned:


S.No.

Priority areas

Activity planned under each priority area

Section C Plan for Performance and Expenditure under each head:


Civil Works / Maintainance
Activity

DTC
TUs
DMCs

Number
required
as per the
norms in
the district

Number
actually
present in
the district

(a)

(b)

Number
planned
for this
year

Please provide
justification if an increase
is planned (use separate
sheet if required)

Estimated
Expenditure
on the activity

(d)

(e)

(c)

Total

85

Quarter in
which the
planned
activity
expected to
be
completed
(f)

Training Course for Program Manager


Laboratory Materials
Activity

Amount
permissible
as per the
norms in the
district

Amount
actually
spent in
the last 4
quarters

Procurement
planned during
the current
financial year
(in Rupees)

(a)

(b)

(c)

Estimated
Expenditure for the
next financial year
for which plan is
being submitted
(Rs.)
(d)

Justification/ Remarks
for (d)

(e)

Purchase of
Lab Materials

Honorarium

Activity

Honorarium for DOT


providers (both tribal
and non tribal
districts)
Honorarium for IP
DOT providers
CP
of Cat IV
patients

Amount
permissible
as per the
norms in
the district
(a)

Amount
actually
spent in
the last
4
quarters
(b)

Expenditure
(in Rs)
planned for
current
financial
year
(c)

Estimated Expenditure
for the next financial
year for which plan is
being submitted
(Rs.)

Justification/
Remarks for (d)

(d)

(e)

Annual Action Plan Format Advocacy, Communication and Social Mobilization


(ACSM) for RNTCP
1) Information on previous years Annual Action Plan
a) Budget proposed in last Annual Action Plan: .
b) Amount released by the state: ..
c) Amount Spent by the district-
2) Permissible budget as per norm :

86

Training Course for Program Manager


Budget for next financial year for the district as per action plan detailed below:
Program
WHY
For
WHAT
Challenges to
WHOM
be tackled by
ACSM
ACSM Activities
ACSM during Objective Target
20__-__
Audience
Based on
Objectives
existing TB
should be
indicators and SMART:
Specific,
analysis of
communication Measurable,
Achievable,
challenges
(Maximum 3 Realistic &
Challenges ) Time bound
objectives

When
Time Frame

By WHOM Monitoring and


Evaluation

Budget

Activities Media/ Q1 Q2 Q3 Q4 Key


Outputs; Outcomes: Total
Material
implementer
expenditure
and RNTCP Evidence Evidence for the
Required
officer
that the that it has activity
responsible activities been
during the
for
have
effective financial
supervision been
year
done

Challenge 1.
Advocacy Activities

Communication Activities

Social Mobilization activities

Challenge 2:
Advocacy Activities

Communication Activities

Social Mobilization
Challenge 3:Advocacy activities

Communication activities

Social Mobilization Activities


TOTAL BUDGET

Comments, if any:Prepared by:-

87

Training Course for Program Manager


Equipment Maintenance:

Item

Office Equipment
(Maintenance includes computer
software and hardware
upgradation,repairs of
photocopier, fax, OHP etc)
Binocular Microscopes (
RNTCP)

Number.
actually
present
in the
district

Amount
actually
spent in
the last
4
quarters

Amount
Proposed for
Maintenance
during
current
financial yr.

(a)

(b)

(c)

Estimated
Expenditure for
the next
financial year
for which plan
is being
submitted
(Rs.)
(d)

Justification/
Remarks for (d)

(e)

Total

Training:
Activity

Training of MOs
Training of LTs of
DMCsGovt + Non Govt
Training of MPWs
Training of MPHS,
pharmacists,
nursing staff, BEO etc
Training of Community
Volunteers (CV)
Training of Private
Practitioners
Other trainings #

Number
in the
district

Number.
already
trained
in
RNTCP

Number planned
to be trained in
RNTCP during
each quarter of
next FY
(c)

Expenditure
(in Rs)
planned for
current
financial
year

(a)

(b)

Q1

(d)

Q2

Re- training of MOs


Re- Training of LTs of
DMCs
Re- Training of MPWs
Re- Training of MPHS
Re- Training of
Pharmacists
Re- Training of
nursing staff, BEO
Re- Training of CVs
Re-training of Pvt
Practitioners
TB/HIV Training of
MOs

88

Q3

Q4

Estimated
Expenditure
for the next
financial
year for
which plan
is being
submitted
(Rs.)
(e)

Justification/
remarks

(f)

Training Course for Program Manager


TB/HIV Training of
STLS, LTs , MPWs,
MPHS, Nursing Staff,
Community
Volunteers etc
TB/HIV Training of
STS
Training of MOs and
key staffs in
Programmatic
management of Drug
resistant TB
Update Training at
various levels(key
staff & MO-PHIs)
Update training of
Paramedical and other
staff ( PMDT )
Any other training
activity( Key staff &
MO-PHIs)
# Please specify

Vehicle Maintenance:
Type of Vehicle

Four Wheelers
Two Wheelers

Number
permissible
as per the
norms in
the district

Number
actually
present

(a)

(b)

Amount
spent on
POL and
Maintenance
in the
previous 4
quarters
(c)

Expenditure
(in Rs)
planned for
current
financial
year
(d)

Estimated
Expenditure for
the next financial
year for which
plan is being
submitted
(Rs.)
(e)

Justification/
remarks

(f)

Total

Vehicle Hiring:
Hiring of
Four
Wheeler

For DTO
For MO-TC

Number
permissible
as per the
norms in the
district

Number
actually
present

Amount
spent in
the
previous 4
quarters

Expenditure
(in Rs)
planned for
current
financial year

(a)

(b)

(c)

(d)

89

Estimated
Expenditure for
the next
financial year
for which plan
is being
submitted (Rs.)
(e)

Justification/
remarks

(f)

Training Course for Program Manager


NGO/ PP Support: (New schemes w.e.f. 01-10-2008)
Activity

ACSM Scheme: TB
advocacy,
communication, and
social mobilization
SC Scheme: Sputum
Collection Centre/s
Transport Scheme:
Sputum Pick-Up and
Transport Service
DMC Scheme:
Designated Microscopy
Cum Treatment Centre
(A & B)
LT Scheme:
Strengthening RNTCP
diagnostic services
Culture and DST
Scheme: Providing
Quality Assured Culture
and Drug Susceptibility
Testing Services
Adherence scheme:
Promoting treatment
adherence
Slum Scheme: Improving
TB control in Urban
Slums
Tuberculosis Unit Model
TB-HIV Scheme:
Delivering TB-HIV
interventions to high HIV
Risk groups (HRGs)

Number.
of
NGOs
currently
involved
in
RNTCP
in the
district
(a)

Additional
enrolment
planned
for this
year

Amount
spent in
the
previous
4
quarters

Expenditure
(in Rs)
planned for
current
financial
year

Estimated
Expenditure for
the next
financial year
for which plan
is being
submitted
(Rs.)

Justification/
remarks

(b)

(c)

(d)

(e)

(f)

TOTAL

Miscellaneous:
Activity*

Amount
permissibl
e as per
the norms
in the
district
(a)

Amoun
t spent
in the
previo
us 4
quarter
s
(b)

Expenditur
e (in Rs)
planned
for current
financial
year

Estimated Expenditure
for the next financial year
for which plan is being
submitted
(Rs.)

Justification/ remarks

(c)

(d)

(e)

Total

* Please mention the main activities proposed to be met out through this head

90

Training Course for Program Manager


Contractual Services:
Activity

Medical OfficerDTC
STS
STLS
TBHV
DEO
Accountant
part time
Contractual
Driver
Contractual LT
Senior TBHIVDOTSPLUS
Supervisor

Number.
required as
per the
norms in the
district

Number.
actually
present
in the
district

Number.
planned to
be
additionally
hired during
this year

(a)

(b)

(c)

Amount
spent in
the
previous
4
quarters

Expenditure
(in Rs)
planned for
current
financial
year

(d)

Estimated
Expenditure
for the next
financial
year for
which plan
is being
submitted
(Rs.)
(e)
-

Justification/
remarks

Total

Printing:
Activity

Printing*

Amount
permissible as
per the norms in
the district
(a)

Amount spent
in the previous
4 quarters
(b)

Expenditure (in
Rs) planned for
current financial
year
(c)

Estimated Expenditure for


the next financial year for
which plan is being
submitted (Rs.)
(d)

Justification/
remarks
(e)

* Please specify items to be printed

Research and Studies:


Any Operational Research project planned (Yes) / (No)
Estimated Budget (to be approved by SHS).___________________________________

Medical Colleges
Activity
Contractual Staff:

Amount permissible
as per norms
(a)

MO (In place: Yes/No)


STLS (In place: Yes/No)
LT (In place: Yes/No)
TBHV (In place: Yes/No)

Research and Studies:


Thesis of PG Student
Operational Research*
Travel Expenses for attending
STF/ZTF meetings
IEC: Meetings and CME planned

TOTAL

91

Estimated Expenditure for


the next financial year(Rs.)
(b)

Justification/
remarks
(c)

Training Course for Program Manager


Procurement of Vehicles:
Vehicles

Number
actually
present in the
district
(a)

4-wheeler **
2-wheeler

Number
planned for
this year

Estimated Expenditure for the next


financial year for which plan is
being submitted (Rs.)

Justification/
remarks

(b)

(c)

(d)

** Only if authorized in writing by the Central TB Division

Procurement of Equipment:
Equipment

Office Equipment
(computer, modem,
scanner, printer, UPS
etc)
Any Other

Number
actually present
in the district

Number
planned for
this year

(a)

(b)

Estimated Expenditure
for the next financial
year for which plan is
being submitted (Rs.)
(c)

Justification/ remarks

(d)

Section D: Summary of proposed budget for the district

Budget estimate for the coming FY 20__-__

S.No.
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16

Category of Expenditure

(To be based on the planned activities and


expenditure in Section C)

Civil works
Laboratory materials
Honorarium
ACSM
Equipment maintenance
Training
Vehicle maintenance
Vehicle hiring
NGO/PP support
Miscellaneous
Contractual services
Printing
Research and studies
Medical Colleges
Procurement vehicles
Procurement equipment
TOTAL

** Only if authorized in writing by the Central TB Division

DTO must ensure that District Health Society reviewed the action plan and approved. In
addition to assisting in logical planning, this would also save time as the member secretary
will not have to seek approval for each individual activity.
District Annual Action Plans are then compiled at the state level and the State Annual
Action Plan is prepared including budget for state level activities, incorporated in the NRHM
State Annual Action plan and submitted. A copy of the State annual action plan is also sent
to Central TB Division. CTD releases lump-sum amount twice a year to the State Health
Society (RNTCP sub-account) for onward distribution to District Health Society (RNTCP
92

Training Course for Program Manager


sub-account) as per their action plans. The format for the preparation of the State Annual
Action Plan is in the Annexure I.
Additionality Funds from NRHM- Details of the activities for which Additionality Funds are
proposed to be sought.

2. Training
An adequate number of trained manpower is critical to the successful implementation of
RNTCP. High quality training has to be imparted at different levels periodically to take care
of promotions, transfers and superannuation through induction training, retraining and
periodic updating.
It is imperative to conduct quality training of all levels of personnel who have TB-related
responsibilities. It is ensured by careful planning that, all types of key personnel who
perform TB-related activities are adequately trained while assuming responsibility of
implementation of RNTCP or any new initiatives under the programme. The entire training
process should be closely monitored by the State / District officials.
Development of training schedule
Since the personnel at each level support and supervise the level directly below them,
generally staff at the state level should be trained prior to the staff at the district level, and
the staff at the district level should be trained prior to the staff at the sub-district and
peripheral levels. To help ensure that the appropriate persons are trained at the correct
time, a training schedule is developed for the staff of the health services and the staff of the
laboratory services separately.
Following factors are considered while developing the training schedule

Training need assessment of the target group


The time by which the training material is ready.
The order in which personnel will be trained;
The duration of the training period for each group;
Number of batches and the number of trainees in each batch to be trained at a time.
Number of each type of personnel (e.g. state, district) to be trained for each quarter
of the year.

Services of the staff from well performing neighboring districts / states can be availed for
training purposes. Well performing districts should be utilized as field demonstration areas
during training whenever possible. All classroom teaching should be demonstrated at these
field sites.
Induction training: Initial training before assuming the responsibilities of the programme
Update training: Newer initiatives or changes in the policy of the programme are to be
conveyed to the health personnel
Re-training / refresher training: Based on training needs of the identified personnel
focused on specific deficits of knowledge or skills

93

Training Course for Program Manager


The tables below will facilitate preparation of training schedule.
RNTCP training- Induction:
Category
STO/MO-STC/STDC
staff/District TB Officer/
TB-HIV co-ordinator/
Assistant Programme
Officer
MO-TC/ Urban TB cocoordinator
MO/DOTS-Plus
coordinator
District Supervisor (TB-HIV
/ DOTS-Plus)

Duration
(working
days)
12

Batch
size

12

Training Material

Central Institute

20

RNTCP MO Modules 1-9,


STCS/ DTCS guidelines,
Financial Management
manual, Procurement + SDS
Manual, Monitoring strategy
RNTCP MO Modules 1-9

20

RNTCP MO Module 1-4

District

12

STDC + DOTSPlus Site

STS (2+6)

12

STLS (10+5)
LT
State Drug Store Staff
/Pharmacist in RNTCP

15
10
3

6
8
25

MPHS

25

TB Health Visitor etc.


MPW/HA etc.
ASHA/USHA/Anganwadi
Worker/ Midwives/
Community Volunteers,
etc.
Private/NGO/ other sector
Medical Practitioners (for
PPM module)
TO / SA
IEC Officer /
Communication facilitators
Data entry operator

2
2
1

25
25
25

MPW Module, then


STS Module (partial) / TB-HIV
Module for STS / DOTS-Plus
module for supervisors
MPW Module, then
STS Module
LT Module, then STLS Module
LT Module
MPW Module/ Manual on Std.
Operating Procedures for State
Drug Store
MPW Module, sections of STS
Module
MPW Module
MPW Module
DOT Provider Module

6 hrs

20

Training Module for Medical


Practitioners

DTC/IMA

6
6

12
Need
based
12

STS Module
Handbook of communication
strategy
MPW module, then Epicentre
training

STDC/District
Central level

Need
based
Need
based

Manual on Financial
Management and Guidelines
Manual on Financial
Management and Guidelines,
DTCS/ STCS guidelines

2+2

Accountants for district

Accountant state level

20

Venue

STDC

STDC
STDC
District
District/TU
District/TU
TU/PHI
TU/PHI
TU/PHI

MPW module &


Epicentre at state
level
State level
Central TB
Division

Initial Training on EQA


Category
EQA (Master Trainers/
Microbiologist)
EQA IRL LTs / Senior LT
of IRL
EQA STDC Dir/ STO

Duration
(days)
5

Batch
Size
10

Training Material
EQA Manual

Central Institute

EQA Manual

Central Institute

15

EQA Manual

Central Institute

94

Venue

Training Course for Program Manager


Initial RNTCP training on TB/HIV
Only for the staff who are not trained in revised modules. There is no stand alone training of TB-HIV.
Category
TB-HIV Master Trainers
STO/ DTO/ MO-DTC/
MOTC
MO
STS/STLS
DOT Provider

Duration
(days)
2
1

Batch
Size
10
10

1/2
1
1/2

30
10
30

Training Material

Venue

TB-HIV Modules
Module for MOs on TB/HIV

State level
State level

Module for MOs on TB/HIV


Module for STS STLS on TB/HIV
Module for Health Workers on TB/HIV

District
District
TU/PHI

RNTCP training on intensified package on TB/HIV (additional module)


Additional and Only after basic training in TB-HIV
Category
TB-HIV Master Trainers
STO/ DTO/ MO-DTC/
MOTC
MO
STS/STLS
DOT Provider

Duration
(days)
2
1

Batch
Size
10
10

1/2
1

30
10
30

Training Material

Venue

TB HIV Modules
Module for MOs on TB/HIV

State level
State level

Module for MOs on TB/HIV


Module for STS STLS on TB/HIV
Module for Health Workers on TB/HIV

District
District
TU/PHI

Initial RNTCP training for Medical College staff


Category of staff
to be trained
Medical Staff
STF
Chairperson
Faculty in charge
of RNTCP
TOTs

Type of training

Place of
training

Trainers

Training material

Duration
(in days)

Concise modular

National
institute
State-level

Central institute
staff
STC/STDC staff

RNTCP Key
facts and concepts
1-9 modules

1*
6

National/
State-level
State-level

Central Institute/
STC/STDC staff
STC/STDC staff

1-9 modules

12
1

MO modules

Medical
college

Faculty in charge
of RNTCP

RNTCP Key
facts and concepts
1-3 modules

Part of Curriculum
+ Sensitization

Medical
College

Faculty in charge
of RNTCP

Curriculum

2-3 hrs**

MO-TC modular
MO-TC modular

HODs and Senior


staff
Other faculty
members
(interested)
PG students/
Residents/ Interns
/UGs
Paramedical staff
Nurses

Concise modular

MPW training

Medical
College

Faculty in charge
of RNTCP

MPW module

Pharmacists

MPW training

Medical
College

Faculty in charge
of RNTCP

MPW module

Other paramedical
staff

MPW training

Medical
College

Faculty in charge
of RNTCP

MPW module

5 days or 12 days modular training for those interested. **Consists of theory classes. Practical training will be imparted during
posting to the Chest or Medicine Departments and the DOTS Cell.

Training and retraining should be planned and undertaken periodically based on training needs
assessment.

95

Training Course for Program Manager


Selection of course facilitators
Classroom training, especially skill-based training, requires effective facilitators to manage,
motivate and evaluate course participants. Practical training requires staff who has actual
experience with RNTCP implementation, including recording and reporting of activities.
Important attributes of good facilitators are

ability to assess the training needs


planning capabilities
leading group discussions
ability to organize and facilitate team functioning and provide supportive supervision
encouraging active participation
listening to others without interruption
good knowledge of the subject
good communication skills
providing constructive feedback during training
should be open to learn himself / herself from the trainings
should take suggestions / feedback from trainees constructively

Promising facilitators for future trainings can be identified during the training of state
and district level staff. Personnel from the general health services, general laboratory
services, and experts in TB from other institutions in the country (e.g. medical or nursing
schools) may all be good candidates for being facilitators.
Facilitators training: During facilitator training, each prospective facilitator should
complete the module(s) they will facilitate. They should read all the training material and
complete all the exercises (e.g. role plays, individual exercises). During the training course,
trainees are encouraged to think about areas which they may find difficult and plan ways to
help make it easier. They are also facilitated to identify ways to answer potential questions
and concerns. Initially these personnel can participate as co-facilitators in a training course
with an experienced facilitator before they start to facilitate independently.

EXERCISE 1
For this exercise, you will work with a colleague to discuss potential problems in planning
course logistics and obtaining resources for training.
Instructions
1. Discuss potential problems in planning course requirements and obtaining resources
for the course. Record your responses on the table below.
2. Identify ways to reduce or eliminate the problems.
Potential problems

Possible causes

Possible solutions

After completing the exercise, module reading may be continued.


Calculation of cost of training
The cost of training is included in the budget for implementing the RNTCP in the respective
state or district. All costs associated with training at the different levels of the RNTCP are to
be planned and budgeted for.
96

Training Course for Program Manager


These costs include:
- Per diem for participants and facilitators (TA / DA /honorarium)
- Travel expenses for participants and facilitators
- Audiovisual equipments
- Printing cost for training materials
- Stationary
- Fee for using a training facility; and
- Refreshments
- Contingent expenses.
Implementation of the training plan

Planning of training should be a part of annual action plan at state and district level
which should include the tentative time schedule for the year decided in consultation
with respective authorities well in advance. The training plans are implemented after the
receipt of the required funds. This will include training the state / district personnel as
mentioned above.

Supervision and evaluation of the training quality and needs


District health units and peripheral levels of health services are visited to observe the
performance of the staff related to RNTCP activities. By this the quality of the training
imparted and training needs can be assessed.
Preparation of supervisory schedules and checklists.
The person who conducts supervisory visits should ensure that the health workers are
performing their job adequately. S/he should observe personnel at work, review records
and forms for completion and accuracy, and speak to the staff about their job
responsibilities, case-finding, treatment outcomes, etc.
Supervisory visits provide an opportunity to evaluate the training programme and to identify
staff who needs to build additional skills, or who have other training needs. Supervision is
the opportunity to give on the job training to such staff if feasible and incase there is no
progress in performance even after on the job training, there is a need for assessing the
quality of training received.
The supervisor should also interact with community leaders and with patients, to assess
their perception of the programme and to discuss with them the means for improving the
services and community support.
A staff member may not be adequately performing his/her job because of lack of skills or
knowledge. The person evaluating the performance must determine the specific skill or
knowledge in which the person is deficient. S/he should recommend and ensure that the
staff member is retrained.
A questionnaire may be used to evaluate quality of training. These include Pre-Test, PostTest and Follow-up of the trainees using the tool (questionnaire / interview).
Transfer of knowledge (gained during the training) into the skills can be assessed after few
months by observing the activities being performed by the personnel on the job and
comparing the same with earlier performance of the similar nature.

97

Training Course for Program Manager


Retraining schedules
Category
STO/STDC staffs
DTO/ MO-TC
STS
STLS
LT
MO/TO/ SA/ IEC Officer
Pharmacist/ Staff Drug Management (State/
District/ TU)
MPHS
TB Health Visitor etc.
MPW/HA etc.
ASHA/USHA/Anganwadi Worker/ Midwives/
Community Volunteers, etc
Community based DOT providers
Accountant
EQA (Master Trs./ Microbiologist)
EQA-IRL LT
EQA (STDC Dir/ STO)
EQA (DTO/MOTC)
EQA (STLS)
TB-HIV(DTO/ MOTC)
TB-HIV (MO)
TB-HIV (STS/STLS)
DOTS PLUS(DTO,MOTC,MOPHI)
DOTS PLUS ( STS,STLS,LT)

Maximum duration
(days)
5
3
2
3
2
2
1

Venue
Central Institute
STDC
STDC
STDC
District
District
District/TU

1
1
1
1

District/TU
TU/PHI
TU/PHI
TU/PHI

1
1
2
2
1
1
1
1
1
1
2
1

TU/PHI
State/District
Central Institute
Central Institute
Central Institute
STDC
District
STDC
District
District
State
District

It is imperative to ensure that the highest quality of training is undertaken by RNTCP. This
is the first step towards achieving technical excellence and success of the programme.

Implementation of advocacy, communication and social mobilization


activities (ACSM)
The term ACSM has three components Advocacy, Communication, and Social
Mobilization and within the context of RNTCP, ACSM refers to health communication
activities in TB care and control. The term IEC / ACSM are generally used
interchangeably; however, RNTCP uses ACSM as being used globally by Stop TB
Strategy.
ACSM activities aim at:
1. Creating awareness among people about the disease (signs and symptoms) diagnosis,
and treatment in order to increase accessibility and utilization of services.
2. Engaging all care providers for providing standardized treatment in order to widen the
scope for providing good quality treatment and diagnostic services to all TB patients in a
patient-friendly environment from whichever health care facility they seek treatment
from.
3. Mobilize communities for engaging them in TB care, and to increase ownership of the
programme by the communities.
It should be remembered that ACSM activities are not substitute to TB control activities.
These are supportive services to enhance the quality of services; widen the reach of
activities and facilitate the process of implementation of TB care services. The term ACSM
98

Training Course for Program Manager


has advantage over IEC as it clearly defined three distinct components Advocacy,
Communication and Social Mobilization.
Advocacy is persuading others to enroll with your cause. The purpose of advocacy is to
achieve specific policy changes, programme changes or resource allocation that benefits
the population involved in this process. These activities are aimed for those who have
influence or a say in decision making and whose intervention will support an achievable
outcome/policy goal. At the state and district level advocacy activities are for decision
makers & opinion leaders.
Communication means transfer of ideas from one person to another person(s). It involves
using media in all its forms to inform, persuade and generate action among people about
TB. Behavior Change Communication (BCC) aims to change knowledge, attitudes and
practices among various groups of people. It frequently informs the public of the services
that exists for diagnosis, and treatment. It relays a series of messages about the disease.
Effective behavior change communication and messages should convey more than just the
medical facts, as these facts on their own do not necessarily motivate people to visit a TB
clinic or complete their treatment. The message should explore the reasons why people do
or do not take action on the information they receive. These are called barriers.
Communication should then focus on changing the actual behavior by addressing the
barriers identified social norms or personal attitudes.
Communication creates an environment through which affected communities can discuss,
debate, organize and communicate their own perspectives on TB. It aims to change
behavior - such as persuading people with symptoms to seek treatment and to foster social
change, supporting processes in the community.
Social Mobilization is engaging all/multiple stakeholders with your cause and extracting
their contribution. In the national and sub-national contexts, social mobilization is a
process of generating public will, by actively securing broad consensus and social
commitment, among all stakeholders, for the control of TB.
Community mobilization is a particular grass root level tool or process, in the context of
wider social mobilization.
The goal of community mobilization is to develop a network of individuals & organizations,
that share, support & agree to work together to achieve behavioral change towards
TB.They should demand high quality services to develop a self-supporting and a self
sustainable system for early voluntary reporting of TB symptomatic. Social mobilization
engages and empowers the community in the fight against TB.
Social mobilization brings together community members and stakeholders to strengthen
community participation for sustainability and self reliance. Social mobilization generates
dialogue, negotiation and consensus among a range of players that include decision
makers, the media, NGOs, opinion leaders, policy makers, the private sector, professional
associations, TB patient networks and religious groups.
A strong and well defined communication strategy has been woven into structure and
design of RNTCP and can be accessed at www.tbcindia.org.
The goal of ACSM is to support efforts for:

Improving case detection and treatment adherence


Combating stigma and discrimination
Empowering people affected by TB
99

Training Course for Program Manager

Mobilizing political commitment and resources for TB.

The RNTCP Communication strategy identi es:

Objectives (Communication needs)


Target groups (Communication players)
Media options to reach target groups (Communication tools).

The emphasis is on decentralized planning and implementation of need based ACSM


activities so as to make them programmatically and culturally relevant. Designated staff has
been provided to support the states (IEC Officer) and districts (Communication Facilitators).
They are responsible for helping and supporting programme managers in the states and
districts in planning and implementing ACSM activities. They are also responsible for
drawing support from other departments/personnel in the states and districts for having
convergence with other disease control activities.
To have standardized messages and synergy throughout the country, prototype material
has been developed at the national level which has been hosted on RNTCP website. The
material at web based IEC Resource centre is for adaptation in the
el d. The states and
districts are encouraged to develop/ reproduce/ modify the material in the light of local
needs and cultural context
Communication Needs Assessment for developing need based ACSM Activities
Needs are defined as relating the expressed or unexpressed requirements of the
community/ group to what is currently being available; or the gap between what exists and
what is required. Identifying the needs is the starting point for any intervention or
developing need based ACSM activities. Needs assessment is a systematic method for
reviewing the health issues. It leads to agreed priorities and resource allocation that will
improve health and reduce inequalities.
It should be remembered that assessment indicates that it is not just a question of
developing a list of needs, but it refers to examining the nature, urgency and priority of
needs. The need assessment is the process of identifying and understanding a problem
and planning a series of actions to deal with it.
The important points should be kept in mind while assessing needs are as follows:

Who is doing the assessment/ or gathering information?


What purpose are the needs assessment intended to accomplish?
Whose needs are to be assessed?- about audiences, influencers, barriers
What resources are available to do need assessments?
How much time is available for gathering information?
How will this information be used?

How to gather information or assess the needs?

Existing data approach- programme data


Key informant Approach- exit interviews, behavior; Interview with the private care
providers;
Survey Approach- Baseline studies, KAP studies, health seeking behavior studies,
Focus Group Interview
Participatory Assessment
100

Training Course for Program Manager


Activities in ACSM
Advocacy
Advocacy focuses on gaining and maintaining the support of and motivates decision
makers, opinion leaders, stakeholders and policy influencers. Media is also a vital target
audience for gaining support to address various communication needs. Public Relations
and lobbying is the most important tool used for advocacy all over the world.
Advocacy is classified as:

Policy advocacy informs senior politicians and administrators how an issue will affect
the country, and actions taken to improve laws and policies e.g. TB medicines to be
made available to everyone free of cost.

Programme advocacy targets opinion leaders at the community level on the need for
local action e.g. Panchayat decided to spend a particular amount of time during each
gram sabha meeting to talk about going for sputum examination if there is 2 weeks or
more cough.

Media advocacy validates the relevance of a subject, puts issues on the public agenda,
and encourage the media to cover TB-related topics regularly and in a responsible
manner so as to raise awareness of possible solutions and problems e.g. sensitive
reporting to combat stigma and discrimination.
Activities for Advocacy

Conducting seminars on TB prevention and control for local officials and community
organizations. To share views and experiences, leading to a better understanding of the
challenges that the program is facing.

Distributing letters and fact sheets to local authorities at all levels and local
organizations to gain support for TB related activities.

Working with journalists and reporters to ensure accurate reporting of TB related issues
and stories.

Organizing meetings and parades each year on World Tuberculosis Day (March 24) at
the district level. Local officials, stakeholders, and community leaders should be
encouraged to participate in these events.

Organizing public meetings to provide information on TB in crowded locations, such as


railways stations and bus stations.

Including topics on TB, such as symptoms and prevention in school curricula.


Communication
Communication helps to create a general awareness and knowledge about an issue.
Over a period of time it also creates a mind frame (opinion) that is ready for change in
behavior. Communication also supports the advocacy and social mobilization
approaches. This approach consists of two main components: Mass Media and IEC.
These two combined provide a vast range of communication tools. The messages and
materials are to be developed and produced at the national level with the states adding
to the developed messages to make them culturally appropriate, localized and more
focused to local audiences and state specific issues and changes.

101

Training Course for Program Manager


Activities for communication

Mass Media This is use of radio, television and print media since they have a wide
reach to the population. It is a powerful tool for raising awareness, building knowledge
and indicating public opinion.

Outdoor advertizing It can enhance the campaign effectivity, recall and longevity as it
is accessible to a large number of people in rural and urban areas.

Information, Education and Communication material This is not only a tool in itself, but
also serves as a direct support for trainings, advocacy and social mobilization activities.
Materials that can be used range from brochures & booklets, pamphlets, flyers &
stickers, posters, calendars, flip charts, flash cards to street plays, songs, mobile
phones, exhibitions, folk media and community radio. There may be range of other
innovative approaches.

Social Mobilization
Social mobilization is a community based approach. The key to success of controlling TB is
to build the momentum for change at the district and community level. A range of different
social mobilization tools can be used, including traditional community theatre, folk media,
art and other performance festivals. These communication forms make use of idiomatic
expressions, which vary from one ethnic community to another and are the basis for
communication within and across generation and community leadership structures.
Activities for social mobilization

Walks this activity is frequently used to mobilize societies and as a means of


generating media attention.

Theatre, Melas, Folk shows, Cultural events this is one of the most cost effective
and useful way of community mobilization.

Health stalls and kiosks this is a great way to create awareness and increase
knowledge about TB at grass root level.

Mobile cinemas, Puppet shows this strategy when combined with a range of other
community activities and service delivery can be effective in supporting the behavior
change process.

Communication with children through debates, competitions, etc. activities


focused on school children are a great way to mobilize children and through them the
communities for a cause.

Partnerships for a multi-sectoral response to TB control, it is imperative to enlist


support and co-ordination with partners such as faith based organizations, public and
private sectors including workplaces, the media and corporate sector.

Interpersonal Communication (IPC) this is a two-way process/dialogue with the


objective of bringing about changes in the level of knowledge and understanding,
attitudes and behavior of individuals, communities, and groups. Communication
happens face to face; verbal or non-verbal, between two persons or more. Interpersonal
communication can be effected through:
o Patient Provider Meeting: Patient provider meetings are usually held at the
health facility to inform patients about the disease, treatment duration, importance
of taking treatment under direct observation of the health care provider/ or
Community DOT provider. These meetings are meant for patients who are
102

Training Course for Program Manager


initiated on treatment. It should be ensured that each patient attends one such
meeting during the treatment. This is an opportunity to provide answer to the
queries and doubts and at the same time motivate patients to complete
treatment.
Patient provider meeting may be held every fortnightly / monthly depending upon
the number of cases at the health facility. Patient provider meetings are in
addition to the one-to-one interaction (interpersonal communication) before the
start of the treatment. There could 8-10 patients in such meetings. The number of
patients in each meeting could be more if the health facility has large number of
patient on treatment at any given point of time.
Communication material such as flip books, patient information booklet, and
display material may be used for making these meeting more interactive. In each
meeting refreshment may be provided.
o Community meetings: Community meetings are usually held in the community/ village.
The purpose of the meeting is to create awareness about signs and symptoms of TB,
availability of diagnosis and free treatment in the nearest health facilities, availability of
good quality drugs in patient wise boxes.
Community meetings can also be held along with meetings organized by other health
departmental activities such as Village Health and Nutrition Days. Each community
meeting may be of 1-2 hours of duration. It may be accompanied with other community
level activities such as street plays etc. followed by interaction and question answer
session.
Community meeting should be interactive, providing information and messages in
simple language. The location of the nearest health facility should be informed to the
people in the community meeting. Flip charts, display material, banners etc should be
displayed at the site of the community meeting. Information material such pamphlets
may be distributed to all those interested to get more information.
There can be 25-50 people in each meeting, but the number may vary depending upon
the location. The number should not be very large. There should be opportunity for free
interaction. These may be held every month/ quarter in different villages. Refreshments
may be provided in each community meeting.

103

Training Course for Program Manager

Key messages and media options for different target groups (Example)

Target
group
Patient
and their
families

General
Public

Health
Care
Providers
(Public
and
private)

Decision
makers/
opinion
leaders

Objectives

Key messages

1.To increase awareness


about signs and symptoms
of TB
2,To ensure treatment
completion and treatment
adherence
3,Empowering patients by
providing information about
the treatment, its duration,
side effects

1.To increase awareness


about signs and symptoms
of TB, diagnosis, duration
of the treatment
2.Informing communities
about the availability of free
diagnosis and treatment
facilities at the nearest
health facility
3.To inform about the
curability of TB and reduce
stigma by involving cured
persons in DOT provision.
1.To sensitize and
advocate about RNTCP
regime
2.To encourage private
care providers to refer
chest symptomatic to the
nearest facility for
diagnosis and treatment
3.To involve care providers
as DOT Providers
1.To persuade decision
makers of the importance
of TB
2. To ensure resources for
TB care

Cough of more than 2


weeks duration could be
due to TB.
Contact nearest health
center for sputum
examination
Sputum examination is
reliable for diagnosing TB.
Good quality drugs for the
entire duration of the
treatment in patient wise
boxes, available free of cost.
TB is fully curable with 6-9
months of anti TB treatment.
Drugs should be taken
under the direct observation
of the health care provider /
community DOT Provider
Community can take
responsibility for DOT
Provision- TB support
groups

Sputum smear microscopy


is the most reliable tool for
diagnosing pulmonary TB
Advocate about the
standardized regimen under
RNTCP.
Treatment should be given
under Direct Observation to
ensure cure
To inform about the
magnitude of the TB
problem
To inform about the action
that will support TB control
activities

Media options

Community level
meetings eg., Mahila
Mandals, Panchayat
meetings, youth clubs.
Outdoor publicity
Out reach activities
(Street plays, folk
media, street
theatre, haats,
melas and
festivals)
Mass media
(electronic media)
Sensitization
meetings
CMEs/Seminars
News
paper/journals
Information
booklets
Electronic media

104

Inter-personal
communication
Patient provider
interaction
meetings
Outdoor publicity
(Hoardings, wall
paintings, posters,
bus panels,
banners etc.)

One to one
meetings
World TB Day
activities
News papers/print
media/ Brochures
Electronic media

Training Course for Program Manager


Developing ACSM Annual Action Plan
ACSM Annual action plan is an integral part of the annual district action plan for RNTCP.
The District TB Officer in the district, and State Tuberculosis Officer (STO) at the state are
responsible for planning, organizing, coordinating, implementing and monitoring all ACSM
activities.
Staff at primary health institutions should be trained in IPC skills. Communication material
should be easily available, prominently displayed and used on a regular basis. The cured
persons may be engaged for ACSM activities.

a. Preparation of ACSM Annual action plan


ACSM annual action Plan is an integral part of the District/State Annual Action plan. ACSM
planning and implementation has to be done in the context of TB control activities in your
district/state.
Steps for developing ACSM Annual Action plan:
Step 1- Identify the Gaps / programme challenges For example- is it low case detection? Or
it is high default rate; or is it low cure rate? If the number of issues is many, then prioritize
for three challenges to be considered in one year plan
Step 2- Brainstorming barriers / challenges that contribute to the gaps- Are these
characteristics of the health system or behavior of healthcare providers / or of the
community that contribute to the gap? Staff working for TB as well as general health system
staff and other stake holders may be involved in this process.
Step 3- Identify the type of barrier i.
ii.
iii.

I = Individual ( patient characteristics, belief, behavior)


G= Group (societal or cultural belief or practice)
S = System (Policies, health system, resource, provider belief & behavior)

Step 4- Assess whether you can improve the situation using ACSM
Step 5- Developing ACSM action plan
Annual Action Plan Format for Advocacy, Communication and Social Mobilization
(ACSM) for RNTCP
1) Information on previous years Annual Action Plan
a) Budget proposed in last Annual Action Plan: .
b) Amount released by the state: ..
c) Amount Spent by the district-
2) Permissible budget as per norm
3) Budget for next financial year for the district as per action plan detailed below: .

105

Training Course for Program Manager


Program
Challenges to
be tackled by
ACSM during
the Year
20010-11
Based on
existing TB
indicators and
analysis of
communication
challenges

(Maximum 3
Challenges )

WHY
ACSM
Objective
Desired
behavior or
action
(make
SMART:
specific,
measurable,
achievable,
realistic &
time bound
objectives)

For
WHOM
Target
Audience

WHAT

When

ACSM Activities

Time Frame

Activities

Media/
Material
Required

Q1

Q2

Q3

By WHOM

Q4

Key
implementer
and RNTCP
officer
responsible
for
supervision

Monitoring and
Evaluation

Outputs;

Outcomes:

Evidence
that the
activities
have
been
done

Evidence
that it has
been
effective

Challenge 1.
Advocacy Activities

Communication Activities

Social Mobilization activities

Challenge 2:
Advocacy Activities

Communication Activities

Social Mobilization
Challenge 3:Advocacy activities

Communication activities

Social Mobilization Activities


TOTAL BUDGET

Comments, if any:Prepared by:Signature of DTO

106

Budget

Total
expenditure
for the
activity
during the
financial
year

Training Course for Program Manager


b. Development of Communication material in the districts and pre-testing
Production and development of communication material should focus on identification of
material to be developed and its usefulness while being cost effective. However, mere
production of material should not be considered as undertaking of ACSM activities.
All material developed should be pre-tested before its bulk production. It is economical to
develop material at state level with the help of a professional agency. State and district
should work in close collaboration for developing new material for different target audience.
For example, posters should be developed keeping in mind the target group, messages,
place of use and quality of material. Small quantities of communication material used more
frequently are desirable than production of bulk material, which is rarely used.
Material developed should contain few key messages, readable and placed at important
locations. The text and images should take into consideration the local cultural context and
the language. For example, poster should have 1-3 key messages and should be of good
quality so that it is used for a longer period of time. In the same way, leaflets or pamphlets
should have few clear messages and few images. The cluttering of messages by putting
too much of text should be avoided.
For types of material to be produced for different target groups, refer to the table above.

c. Implement ACSM activities as per the action plan


ACSM activities should be implemented as per the action plan. Responsibilities should be
fixed at district and sub-district level for organization of these activities. DTO and MO-TCs
are to ensure that the activities take place as per action plan. The help and cooperation
from district education officer/block extension educator/media officer and IEC officer at the
state level may be sought for organization of activities.

d. Monitoring, supervision and evaluation


Regular monitoring and supervision of ACSM activities should form a part of routine
supervisory visits. The feedback from the field is critical for modification and or fine tuning of
ACSM activities. Regular monitoring and periodic reviews should be conducted to assess
the value and utility of campaign. Periodic evaluation should be conducted by an
independent agency to evaluate the impact of ACSM activities undertaken.
4. Engaging all care providers
India has the largest private sector in the world that manages a considerable proportion of
tuberculosis cases without notifying them. A few available studies of the health-seeking
behavior of TB symptomatic individuals and patients have shown that more than 50% of
patients first approach the private health sector. The NGOs and private providers are often
closer to and more trusted by patients and perform an active role in health promotion in the
community.
Tuberculosis is encountered at all levels and by all types of health services ranging from
primary health care services to the highly specialized hospitals in the different health care
sectors. Traditionally, control of tuberculosis was considered a responsibility of the public
health sector. As a consequence, tuberculosis control programmes were designed to be
implemented through the available network of public health services. Over the years, the
private sector has grown considerably in India. The private health sector in India varies
107

Training Course for Program Manager


considerably in its size, composition, and level of organization, types of services delivered
and socio-economic groups served.
Public Private Mix (PPM) includes Public-public, Public-private, Privateprivate
partnerships. While involving the private sector and other sectors, it is important to have a
well-functioning RNTCP in the public sector first. The RNTCP experience shows that
through the involvement of PPM the case detection improves.
There is a need to involve all the health facilities under RNTCP to have an
epidemiological impact through standard management of TB cases
The government of India developed guidelines for NGO and private sector involvement in
TB control which were published in 2000 and 2001 respectively, which were revised in 2008
to address newer initiatives like DOTS plus, TB- HIV collaboration and improvement of the
access of DOTS for the TB patients.

PPM providers
PPM is an integral part of RNTCP and the programme encourages involvement of all care
providers throughout the country to meet the objectives of the programme. However
disaggregated data on types of care providers is not captured throughout the country.
For the surveillance purpose RNTCP has identified 14 PPM sites in the country and
disaggregated data is being collected on quarterly basis classifying the care providers in
five types as below:

Government facilities outside health department (G)


Medical College (M)
Private Providers (P)
Non-Government Organizations (N)
Corporate & Other Sectors (C)

Government facilities outside health department


All health establishments under ESI, Railways, CGHS, Defence, Petroleum & Natural Gas,
Chemical & Fertilizer, Coal, Steel, Mines, Power, Ports and Prisons come under this group.
Medical College includes both public and private institutions

Private Providers
They can be from
Private Hospitals & Nursing Homes, Private Practitioners (PPs) practicing allopathy
and allopathic Chemist Shops
Other Systems of Medicine
Traditional healers

Revised schemes for NGOs and private providers


The following are the 10 schemes available for implementation by NGOs and private
Providers
ACSM Scheme: TB advocacy, communication, and social mobilization
Sputum Collection Scheme: Sputum Collection Centre/s
Transport Scheme
DMC Scheme: Designated Microscopy Cum Treatment Centre (A & B)
108

Training Course for Program Manager


LT Scheme: Strengthening RNTCP diagnostic services
Culture and DST Scheme: Providing Quality Assured Culture and Drug Susceptibility
Testing Services
Adherence scheme: Promoting treatment adherence
Slum Scheme: Improving TB control in Urban Slums
Tuberculosis Unit Model
TB-HIV Scheme: Delivering TB-HIV interventions to high HIV Risk groups (HRGs)
ACSM Scheme: TB advocacy, communication, and social mobilization
There is an unmet need for improved advocacy, communication, and social mobilization
(ACSM) to support ongoing TB control efforts in the districts. Improved ACSM is expected
to achieve the following outcomes:

Mobilization of local political commitment and resources for TB.


Improvement in case detection and treatment adherence.
Empowerment of people and communities affected by TB.
Reduction of stigma and discrimination against persons and families affected by TB.

The NGOs are expected to coordinate with District RNTCP units to implement a minimum
set of advocacy, communication, and social mobilization interventions in a district, either by
themselves or with partners. Implementing partners can include Panchayat Raj Institutions
(PRI), Self-Help Groups (SHG), Faith-Based Organizations (FBOs), Community-based
organizations (CBOs), Rotary Club chapters, other NGOs, etc. The activities should reach
an area with a minimum of 5, 00,000 (0.5million) population, but preferably should cover 10,
00,000 (1million) population or greater.
Eligibility and grants
Registered NGOs with capacity and commitment with at least 2 years experience in social
mobilization activities and grass root level activities are eligible. Local presence and
familiarity with local culture will be desirable.
An amount of Rs 1,50,000 per 1 million population per year ( pro-rata for population
covered) is available under this scheme.
The role of the DTO/STO will include joint planning with the NGO for identification of issues
that need to be addressed to strengthen ACSM component. DHS will help the NGO in
identification of pockets within the district which needs attention for awareness generation,
social mobilization and community empowerment

SC Scheme: Sputum Collection Centre/s


RNTCP has established over 12,700 Designated Microscopy Centres (DMCs) in the entire
country, but there are still areas where accessibility to DMCs is difficult. The expansion of
the DMC network is limited due to the strict requirement for quality assurance of services
and for maintaining proficiency of laboratory technicians. Hence in these areas with suboptimal access to DMCs, it is envisaged that NGO/private provider supported sputum
collection centres can be established to provide ease of accessibility to patients. Sputum
specimens collected will be transported to the nearest DMC, enhancing the coverage of
RNTCP and improving convenience to patients.

109

Training Course for Program Manager


Eligibility
Any institution in under-served areas with convenient access at appropriate times to the
population served is eligible under this scheme. Underserved areas are defined as those
settings with justifiably difficult access to microscopy services. This may be difficulty based
on distance, poor public transport network connectivity, population characteristics that
complicate access to existing DMCs (e.g. a slum in an urban area, or tribal village). The
institution should have a conducive area for sputum Collection, including well ventilated
open spaces for sputum expectoration. The manpower to conduct the related activities as
per RNTCP guidelines should be present.
Role of NGO/Collaborating partner

Collection of sputum for diagnostic and follow-up examination as per RNTCP


guidelines.
Ensuring accurate recording in lab forms and dispatch lists, labeling, recording and
packaging of samples,
Ensuring that a mechanism for transportation is in place and that there is timely
communication of sputum results back to referring providers.

Standardized kits for transportation are to be procured by the NGOs


Grant in aid: Based on estimate of Rs. 3000 facility cost reimbursement(not to be
reimbursed if a govt premises are used) and Rs 2000 service cost reimbursement
(monthly), a total reimbursement of Rs 60,000/- per annum per sputum collection centre,
lump sum has been established. Rupees three hundred and fifty per sputum collection box
is to be reimbursed by District Health Society (DHS). The number of boxes provided by
DHS can be worked out according to the workload, and be included in the MOU.

Transport Scheme: Sputum Pick-Up and Transport Service


In this scheme, the programme envisages a Sputum specimen Pick-up and Transport
Service of samples by non governmental organizations or private agencies having their
presence in the identified areas. Provision of such services would enable the programme to
access the under-served populations of the country, enhancing the coverage of RNTCP
and improving convenience to patients.
Eligibility
NGO / Community Based Organisation (CBO) with outreach workers or private organization
with the capacity to transport sputum specimens as per RNTCP guidelines are eligible.
Role of NGO/Collaborating partner

Coordination with Sputum Collection Centres, safe transportation of samples to


DMC.
Communication of results in dispatch lists and forms to the Sputum Collection
Centres.
Maintenance of travel log book.

110

Training Course for Program Manager


Role of RNTCP (DTO/STO)

Planning and allocation of Sputum Collection Scheme and transportation in


collaboration with MO-DMC and external partners
Training of the concerned staff and provision of materials listed
Ensuring quality microscopy and timely transmission of results

Grant-in-aid: Rs 24,000 per annum (for a maximum of 20 visits per month)

DMC Scheme: Designated Microscopy Cum Treatment Centre (A & B)


A. Designated Microscopy and Treatment Centre
B. Designated Microscopy Centre- Microscopy only
A. Designated Microscopy and Treatment Centre
Role of the NGO
The laboratory serves as a microscopy and treatment centre and is designated as DMC
and provides services free of charge.
Technical policy for collection, examination of sputum, provision of anti-TB treatment,
record-keeping and quality control are also to be done as per NTCP policy.
Role of the District Health Society/District TB Centre
The TB Programme will provide training and technical guidance and will perform laboratory
quality control. In addition, the programme will assist the NGO/private facility in ensuring
evaluation of smear-positive patients who live outside the catchment area of the
NGO/private facility and have been referred by the NGO for treatment.
Commodity Assistance
The RNTCP will provide commodity assistance of laboratory materials and reagents, forms
and TB Laboratory Register. Anti-TB drugs will also be provided for patients, started on
RNTCP treatment.
Grant-in-Aid
Annual grant-in-aid of Rs 1,50,000 is available under the scheme.
Eligibility Criteria
The NGO must be registered under the Societies Registration Act, and should have a
minimum of 3 years experience in the area of operation and availability of necessary
infrastructure.
B. Designated Microscopy Centre- Microscopy only
A private health facility having its own laboratory serves as an approved microscopy centre.
Patients are not charged for AFB microscopy and the materials for microscopy are provided
to the microscopy centre by the programme.
Private Practitioner Role
All the procedures are to be carried out as per RNTCP guidelines and services should be
provided free of cost.
111

Training Course for Program Manager


Grant-in-Aid
Rs 25 per slide, but subject to a cap and revocation if fewer than 5% of suspects examined
are found to be AFB positive.
Eligibility Criteria
The health facility must have available necessary infrastructure, a trained microscopist, and
a room for the laboratory. The health facility staff must undergo modular training in
microscopy as per RNTCP guidelines; only specified LTs who have been successfully
trained will conduct sputum examinations.
LT Scheme: Strengthening RNTCP diagnostic services
This activity under the scheme for case detection is applicable in settings where there is a
need for operating a RNTCP-designated microscopy centre, based on population
considerations and workload, but where the constraint in human resource (Laboratory
Technician) has prevented the establishment of a designated microscopy centre, or its
effective and uninterrupted functioning. The infrastructure of the proposed designated
microscopy centre under this activity should be under the public sector (e.g. health
department of the state/centre, medical colleges, other public sector health facilities like
ESI, public sector undertakings, etc). In such an identified laboratory a NGO partner
working under this scheme could provide a solution for the human resource constraint by
providing contractual laboratory technician(s) who will be recruited and maintained by the
partner NGO, but will be assigned to work under the head of the health facility in which the
designated microscopy centre is located.
This support by the NGO should be provided to address short term human resource
constraints, usually not exceeding 3 years. Every effort should be made by the local
RNTCP programme manager to address in the long term this human resource constraint
through the government health system and initiatives/projects that target health system
strengthening.
Eligibility & Grant-in-aid: Any registered NGO with capacity and commitment to provide
sustained support for at least 3 years is eligible. Amount equal to current salary of existing
RNTCP contractual Lab Technician , plus 5% overhead expenses, and recruitment cost
reimbursement equal to one month salary is the grant-in-aid eligible for NGO. The
recruitment cost, salary and overheads will be borne either by the partner NGO, or by
RNTCP.
Role of NGO/Collaborating partner

Recruitment of a laboratory technician, maintenance of the person on payroll and


regular salary payments,
Deployment of the person to work at the identified designated microscopy centre, `
supervision and monitoring of laboratory technician performance
In cases where this activity will be funded by the NGO, the responsibility of resource
mobilization will lie with the NGO.

Role of RNTCP (DTO/STO)

Joint planning and coordination with the NGO,


Imparting training to the concerned staff,
112

Training Course for Program Manager

Implementation of quality assessment protocol


Supervision and monitoring of the performance of the laboratory technician.

Culture and DST Scheme: Providing Quality Assured Culture and Drug
Susceptibility Testing Services
The programme is in the process of establishing a nation-wide network of quality assured
sputum / specimen culture and drug susceptibility testing (C&DST) laboratories for the
diagnosis and follow-up of multi-drug resistant TB (MDR-TB) patients in the nongovernment sector.
Eligibility: An existing well-functioning mycobacterium culture and DST laboratory in the
private/NGO sector can apply under this scheme. The applicant laboratory should have
adequate infrastructure, equipment and staff to undertake the sputum culture & DST
activities. The sputum culture and DST services are to be free of charge to all patients
referred by the programme.
Grant-in -aid : The initial payment by RNTCP will be based on a pre-decided number of
MDR suspects as per RNTCP DOTS-Plus implementation plans. The fee payable for
sputum / smear, culture, species identification and drug susceptibility testing for at least the
4 first line anti-TB drugs, namely Rifampicin, Isoniazid , Ethambutol, and Streptomycin, will
be Rs.2,000/- per specimen, and for undertaking smear, culture and species identification
will be Rs.400/- per specimen.
Responsibilities of the NGO/Private Facility: Establishment and maintenance of this
facility will be as per NTCP guidelines.

Adherence scheme: Promoting treatment adherence


Non-governmental organizations (NGOs) have a long history of supporting health services
at the community level, often with remarkable effectiveness and rapport with communities.
Individual Private Hospitals, Nursing Homes, Clinics, and Private providers (PPs) also have
many successful examples of delivering high-quality tuberculosis services to communities
in cooperation with the TB programme, to the benefit of all. PPs are often more accessible
to patients than public health services in terms of distance and convenience of timings,
especially in urban areas.
Eligibility : NGOs: The NGO registered under the Societies Registration Act, (1860)
should have a minimum of one year experience in Out-reach work in health or in related
fields and have the necessary infrastructure. Private Providers: PP should preferably
have undergone training in at least the RNTCP module for Private Practitioners, or at least
staff from the clinic should have undergone RNTCP DOT provider module training.
Role of the NGO
DOT services:

Identification of DOT providers, training and supervision of their activities.


Provision of DOT - free of cost
Maintenance of procedures and records as per NTCP policy

113

Training Course for Program Manager


Counseling services for patients and families
Counseling services include emotional support, information on symptoms, disease,
duration of treatment, importance of DOT adherence, side effects and referrals
Defaulter retrieval actions
Additional services:
Transportation of patient wise boxes and treatment cards from the PHIs to the DOT
centers and vice versa.
Maintenance of records of such transfers

Role of the Private Providers


i.
ii.
iii.
iv.
v.
vi.

Undertaking initial home visit for address verification,


Counselling of patient and family members.
Provision of DOT
Provide INH chemoprophylaxis
Initial retrieval actions for missed doses.
Recording and reporting as per RNTCP guidelines.

Grant-in-aid
For NGOs supervising DOT services:
Administrative and additional treatment support functions: Rs 40,000 for every 1 lakh
population per annum, on pro-rata basis for population served.
For DOT:
For patients put first line regimen: Rs250 to the individual volunteer for each patient
cured or treatment completed
For MDR-TB patients put on DOTS PLUS regimen : Rs 2500/- (Rs 1000/- for IP and Rs
1500/- for CP) to the individual volunteer for each patient treatment completed, to be
disbursed in two installments.

Grant-in-aid (PPs):
PPs providing DOT

Rs 400/- per patient successfully treated with all services (i) (v) listed above for PPs,
i.e. treatment including initial home visit and default retrieval
Rs 250/- per patient successfully treated [If services in item (i) & (v) are not
undertaken] The NGO will be reimbursed at the rate of Rs 150/- per patient for
cured/treatment completed, for undertaking services (i) & (v). If these are activities are
undertaken by the General Health Staff, no honorarium will be paid.
For MDR-TB patients, Rs.2,500/- per patient successfully treated with all the services (i)
to (v) listed above [Rs 1000 after completion of IP and Rs 1500 after completion of CP].

Slum Scheme: Improving TB control in Urban Slums


Despite the supposed proximity of the urban poor to urban health facilities, their
accessibility may be limited by inadequacies in the urban public health delivery system.
Slum dwellers are often migrants, with different language and cultures. Women are often
engaged in work and manual labor, and may have limited time available to address health
care needs. There are high concentrations of particular occupations such as rickshaw
pullers, rag pickers, sex workers, and other urban poor categories like beggars and
114

Training Course for Program Manager


destitutes, construction site workers, alcoholics, drug abusers, street children. These
groups are highly vulnerable to HIV/AIDS. Poor environmental conditions in the slums,
along with high population density, make slum-dwellers more vulnerable to tuberculosis and
other diseases of poverty. Urban slum-dwellers require intensive focus and support from
the tuberculosis programme.
Eligibility
Any NGO/Community based organization/Self help group/Private practitioner with capacity
and commitment to provide sustained support for at least 3 years is eligible for this scheme.
Role of NGO/Collaborating partner

Organization of IEC activities in slum population for TB and service awareness


Counselling patients for completion of diagnostic process, treatment initiation, treatment
adherence, information regarding pending migration, and default prevention
Collection of contact details and other information helpful to locate patients in the case
of migration.
Address verification for patients.
Addressing special needs of patients, such as drug abuse, alcohol addiction
Facilitation of sputum collection and transportation to DMCs
Provision of DOT as per RNTCP guidelines
Defaulter retrieval of patients.
Communication of impending migration of patients information to RNTCP staff

Grant-in-aid:
Rs.50,000 per 20,000 population per annum is available under the scheme.

Tuberculosis Unit Model


The NGO provides all RNTCP services earmarked for a Tuberculosis Unit (TU;
approximately 5 lakh population). As per NTCP policy, in general, this should only be
considered in areas where the governmental infrastructure is not sufficient to ensure
effective RNTCP implementation. One NGO may cover more than one TU, but must meet
all eligibility criteria for each TU.
Role of the NGO
The NGO ensures full services for microscopy, treatment, direct observation, defaulter
retrieval, recording and registration, supervision as per guidelines. It is of utmost
importance that the NGO scrupulously maintains RNTCP records and submits quarterly
reports to the District TB Officer in time in the prescribed format.
Commodity Assistance In kind:
The RNTCP will provide materials for training and implementation, including formats and
registers; and in kind, provision of anti-TB drugs, cotrimoxazole (if necessary) and
microscopes. If required, a 2-wheeler for mobility of the STS/STLS will be provided.
Laboratory consumables may be provided in kind or as grant-in-aid.

115

Training Course for Program Manager


Eligibility Criteria:
The NGO must be registered under the Societies Registration Act, having a minimum of 3
years experience in health care. It should have the infrastructure, staff, or volunteers
required in the field. The NGO should give a specific undertaking to the District Health
Society indicating its commitment to provide effective, uninterrupted service in the area as
per RNTCP policy.

TB-HIV Scheme: Delivering TB-HIV interventions to high HIV Risk groups


(HRGs)
Targeted Intervention Programmes have been undertaken for various categories of
vulnerable population like commercial sex workers, truck drivers, MSM, eunuchs, etc. The
concept of Targeted interventions is based on the pillar of community ownership. These
populations are at high risk of getting HIV infection and also most often marginalized by
society, likely to be poor and difficult to reach by the programme. NGOs undertaking these
targeted interventions utilize peer educators to detect these populations, build bridges, and
provide a package of preventive and curative services for the targeted communities.
Even though this target population is expected to have high TB prevalence (TB being the
most common Opportunistic Infection), the package of services currently does not include
TB care. As these populations have a high prevalence of HIV infection and are likely to be
marginalized by the society they have special needs. Hence, they do not often access
general health services. TB care and HIV-TB interventions can be offered via these NGOs
who are already working with them successfully for health promotion. Furthermore, delivery
of TB treatment under DOT by general health services to these populations is a challenge
due to issues like high mobility and stigma.
However, schemes based on general population norms will not be available to NGOs
serving scattered and heterogeneous target populations. These NGOs could be covering a
number of very localized geographical areas like brothel based commercial sex workers,
community care centres or huge geographic areas focusing smaller but more challenging
populations like street based sex workers. Hence a dedicated RNTCP scheme is required
to ensure equity of access and to expand TB-HIV interventions into these challenging
populations.
Eligibility: The following are eligible under this scheme.

NGOs already undertaking NACP Targeted Intervention in identified HIV high


populations and catering to a minimum of 1000 target population of Commercial sex
workers (CSW), MSM (Men having Sex with Men), and/or IDUs (Intravenous Drug
Users).

NGOs running a NACP accredited/funded Community Care Centre for HIV, with at least
20 beds.

NGO should already be providing HIV care, including clinical care to the above
described High risk populations and undertaking outreach activities in these populations

NGOs being offered the RNTCP scheme should be willing to undertake delivery of
comprehensive TB care i.e., all components as described below in the TB-HIV Scheme.

116

Training Course for Program Manager


Role of NGO/Collaborating partner
Under the proposed scheme NGO would undertake delivery of Comprehensive TB Care
for HIV high risk populations which includes all of the following components:
1) Intensified TB Case Finding:
Symptom screening through outreach workers and peer educators & referral of suspects
for diagnosis & treatment
2) Patient friendly approach for Diagnosis and treatment:
a) Sputum collection & transportation or facilitating referrals
b) Coordination with existing government health facilities for the diagnosis of smear
negative pulmonary TB and Extra-pulmonary TB.
c) Allocation of treatment regimen.
3) Verification of address before initiation of TB treatment
4) Treatment provision:
a) Identification and Organization of Treatment.
5) Adherence:
a) Retrieval of patients in case of treatment interruption;
b) Coordination with local programme staff
c) Monitoring, Supervision & Recording by NGOs
6) Monthly meeting: DTO and NGO
7) Outreach activities by NGOs,
a) Increase visibility of RNTCP for HRG (High Risk Group).
b) Community capacity building/CBO/community involvement in TB services
c) Advocacy with PLWHA networks for TB control
Role of RNTCP (DTO/STO)

Training of NGO and Service providers


Provision of logistics
Supervision, monitoring and evaluation of NGO activities and patient care
Provision of honorarium for individual DOT providers as per RNTCP norms.

Grant-in-aid:
An amount of Rs 1,20,000 per NGO per 1,000 Target population is available under this
scheme.

Procedures for collaborative activities under different schemes:


1. Type and the number of schemes: An NGO / Private provider is eligible to adopt either
one or more schemes
2. Approving authority:
a. ACSM scheme, sputum collection centre, sputum pick-up & transport and treatment
adherence schemes: District Health Society approves and establishes collaboration
with NGO/PP without consultation with higher authorities. A copy of the relevant
Memorandum of Understanding will be sent to the State TB Centre and Central TB
Division for information.
117

Training Course for Program Manager


b. DMC Scheme, LT Scheme, Slum Scheme, TB HIV Scheme: State TB Cell is the
approving authority, following recommendations by the DHS. A copy of the MOU will
be sent to Central TB Division for information.
c. Culture-DST Scheme, Tuberculosis Unit Scheme: Central TB Division is the
approving authority following the recommendations by DHS and State TB Cell. A
copy of the MOU should be sent to STC and CTD for information.
3. Period of Assistance: The MOU is usually for a period of one year. It is subject to
renewal based on the satisfactory performance as evaluated and recommended by
DHS. The contract can be terminated at any time without prior notice either due to poor
performance or non-diligence
4. Remuneration: Salary of the staff employed under different schemes should be at par
with the appropriate staff employed under the programme.
Systematic process of involvement of health facilities under PPM
1. Sensitization of administrators and opinion leaders
2. Orientation of RNTCP staff on PPM DOTS
3. Listing of PPM health care providers
4. Identification / verification of PPM facility
5. Sensitization of PPM Providers
6. Administrative approval
7. Training of PPM providers
8. Signing of RNTCP MOU (Memorandum of Understanding)
9. Start of service delivery

5.

Involvement of Medical Colleges in the RNTCP

Medical colleges play an important role in supporting any health programme in India.
Medical college faculty have an important role in TB control as opinion leaders and
trendsetters, teachers, imparting knowledge, skills and as partners in sustaining the
programme by teaching and practicing DOTS and as role models for practicing physicians.
Recognizing the signi cant role medical colleges can play, the RNTCP envisaged activities
pertaining to training and teaching, service delivery, advocacy and operational research as
priority areas for collaboration with the medical colleges.
A National Task Force (NTF) and five Zonal Task Forces (ZTF) have been formed for their
effective involvement in RNTCP. Within each zone, nominated medical colleges have been
given the responsibility to function as nodal centers. All states which have medical colleges
have formed State Task Forces (STF). In each medical college, there should be a core
committee to arrange for training and oversee the functioning of the microscopy / treatment
118

Training Course for Program Manager


centre in their respective institutions. Continuing success of RNTCP requires involvement of
all large healthcare providers including medical colleges.
Similarly Operational Research committees are formed at national, zonal & state level
which coordinate with Task forces and the state & district officer for approval of submitted
OR proposals representing the medical colleges.
Task Force
For effective implementation of the programme in medical colleges, the programme
functions through a Task Force mechanism at the National, Zonal and State levels. By
February 2006, State Task Forces were formed in all 27 States/UTs with medical colleges.
Zonal Task Force
Zonal task forces have been constituted in ve zones of the country, catering to the medical
colleges located in the north, south, east, west and north east zones of the country. RNTCP
has established seven nodal centers for medical college involvement across the country at:
1.
2.
3.
4.
5.
6.
7.

AIIMS (New Delhi)


Post Graduate Institute of Medicine (Chandigarh)
SMS Medical College (Jaipur)
LTM Medical College (Mumbai)
Guwahati Medical College (Guwahati)
Christian Medical College (Vellore)
R G Kar Medical College (Kolkata).

These nodal centres are actively involved in the Zonal Task Forces and in the National
Task Force.
Workshops for Task Force
By holding annual workshops at the zonal and national level, RNTCP provides a platform
for the Medical college faculty for sharing experiences and for streamlining the bottlenecks
identi ed in effective collaboration.
National Task Force (NTF)
Composition: Chairman: DDG (TB)
Member Secretary: one from the nodal medical colleges on rotation basis.
Members: One each from CTD, 7 nodal medical colleges, TRC, NTI, LRS and WHO.
The main task of NTF is to provide leadership and advocacy, coordination, monitoring, and
policy development on issues related to effective involvement of medical colleges in
RNTCP.
Zonal Task Force (ZTF)
Composition: Chairman: Representative from the nodal centre (where more than 1 nodal
centre, on rotation basis after 2 years). The list of nodal centres is on page 198.
Member Secretary: STO of the State where nodal centre is located
119

Training Course for Program Manager


Members: Representatives of the State Task forces (1 medical college per State) and
STOs of the States within the zone
Functions
1. Ensure that State Task Force (STF) are formed in all States
2. Compile and update the list of Medical Colleges with their RNTCP implementation
status
3. Organize ZTF meetings to review progress and draw up annual action plans
4. Ensure training of ZTF members
5. Organize zonal level CMEs/Seminars/workshops and other academic activities for
medical colleges and the private sector at least once a year
6. Facilitate operational research by medical colleges
7. Field visits / attend meetings of STF, workshops etc. All States are to be visited at least
once every quarter. Field visits should be conducted jointly by members of ZTF and STF
in coordination with the STO.
8. Disseminate information about RNTCP to medical colleges.
State Task Force (STF)
Composition: Chairman: Representative from medical college to be elected
Member Secretary: STO of the State
Members: One representative from each college, on rotation basis if required
Functions
1. Ensure establishment of DMC cum DOT centers in all Medical Colleges located in
RNTCP implementing districts.
2. Disseminate information about RNTCP to medical colleges..
3. Help organize training for core committee members of individual medical colleges.
4. Visit every Medical College at least twice a year.
5. Organize State level CMEs/Seminars/workshops and other academic activities for
Medical Colleges and the private sector at least twice a year.
6. Hold STF meetings once in a quarter to review progress / performance of medical
colleges in the State.
7. Plan future activities.
8. Define priorities for operational research based on the national and zonal workshop.
Review research proposals and facilitate in conduction of research by medical colleges.
9. Key role in establishing diagnostic and treatment facilities under DOTS-Plus
Medical College core committee
Composition: At least 4 members with representatives from department of medicine, chest
medicine, microbiology and community medicine. Coordination of TB control activities is
done by District TB Officer (DTO).
Functions
1. Establish DMC cum DOT centre in all medical college hospitals, even if the DTC is
within the same premises of the medical college.
2. Organize sensitization / workshops / trainings for faculty members, PGs, UGs, Interns,
paramedical staff, etc.
120

Training Course for Program Manager


3. Ensure that teaching on TB/RNTCP form part of curriculum for PG students/ Residents /
Interns / UGs. Teaching should include practical training through visits to DOT centres
as well as classes taken by departments of Medicine, TB & Chest Medicine,
Microbiology, Community Medicine etc.
4. Coordination between various departments so that patients get the services in respect
of their TB problem under one roof.
5. Coordinate with the district TB programme for participation in the quality assurance
network of sputum microscopy, referral network, management of complicated cases of
TB, and submission of monthly PHI report.
6. Undertake operational research for RNTCP on the priority areas defined by the STF for
the State. Encourage research on TB by faculty as well as by students for their thesis
etc.
7. Undertake advocacy for the programme by publishing articles on TB, newsletters, radio /
TV talks, etc
8. Hold Monthly meeting to review performance of the DMC cum DOT centre in the
hospital.
9. Submit a compiled quarterly report of the DMC cum DOT centre to the STF
Sensitization training on RNTCP in medical colleges
All Medical staff at Medical colleges should be sensitized for one day. The interested faculty
members/ those identified by HOD can then be trained for the full 5 days. However the staff
in-charge of the DOT centre at Medical College should receive full 12-day training in
modules 1-8. This should include buffer staff to allow for possible leave / transfer of the
staff otherwise designated for the purpose. DOT provider training is imparted to
Paramedical staff using the MPW module for 2 days. Faculty members from Medical
College would be drafted as trainers / facilitators.
STO/DTO should undertake the following activities for involvement of medical
college hospitals in the RNTCP
1. Involvement of all Medical college hospitals in RNTCP. Formation of Core committee
Regular meetings for discussing the issues of coordination, training, referral and transfer
mechanisms
2. Consultation with the Medical Colleges in conducting sensitization workshops on
RNTCP for faculty members where the same has not been done.
3. Organization of RNTCP training of Medical officers, Laboratory Technician and DOT
providers and other staff as required.
4. Provision of Binocular Microscopes wherever required and upgradation of laboratory for
the Microscopy centres. Laboratory consumables, forms and registers required should
be provided by the State/District TB Cell.
5. Provision of 100% requirement of RNTCP drugs
6. Ensure supervision of the laboratory and treatment services and assist in patient
retrieval wherever necessary.
7. Provide technical inputs, guidance and supervision as per programme
Additional contractual staff are provided wherever required to implement and coordinate the
activities of RNTCP in Medical Colleges/Hospitals as per provisions under the programme
(1 Medical Officer, with approval from CTD & 1 Laboratory Technician and 1 TB Health
Visitor which the STO can sanction) In addition to the above, co-ordinate with
Deans/Directors of the Medical College hospitals so that they:
121

Training Course for Program Manager


1. Provide space for a Microscopy Centre in the hospital.
2. Identify one senior faculty member, preferably from the Dept. of TB & Chest or from
Medicine as a nodal person for RNTCP activities.
3. Designate one Laboratory Technician for DMC and one health worker as DOT provider
(treatment observer). It should be ensured that the designated staff especially the LT
has sufficient time for RNTCP work.
4. Issue directions to the major OPDs of the college/hospital to refer all patients with cough
of 2 weeks or more to the DMC of the hospital.
5. Ensure availability of faculty members for sensitization regarding the RNTCP and for
training of key staff like the MO in charge of the DMC, LT and DOT providers.
6. Issue instructions to all the doctors to follow RNTCP diagnostic algorithm for all patients
and standardized treatment policies as per the RNTCP. Proper referral of patients who
reside outside the district in which Medical College is situated should be undertaken with
the help of the staff in the hospital DMC.
7. Stop procurement of anti-TB drugs except for those patients who are critically ill and
require in-door and specialized treatment. RNTCP drugs should be used for majority of
TB patients.
8. Agree to supervision by RNTCP staff and submit reports as required under the RNTCP.
Nodal Centres
Zones

Nodal centres

States covered by the zones

East

RG Kar Medical College, Kolkata

West

Lokmanya Tilak Municipal Medical


College and Hospital, Mumbai
SMS Medical College, Jaipur

West Bengal, Bihar, Jharkhand,


Orissa, Chhattisgarh
Maharashtra, Goa, Madhya Pradesh

North

South
North
East

All India Institute of Medical Sciences,


New Delhi
Post Graduate Institute of Medical
Education and Research, Chandigarh
Christian Medical College, Vellore,
Tamil Nadu
Guwahati Medical College, Guwahati,
Assam

Gujarat, Rajasthan,
Uttar Pradesh, Delhi, Jammu &
Kashmir, Uttaranchal
Punjab, Chandigarh, Haryana,
Himachal Pradesh
Andhra Pradesh, Karnataka, Kerala,
Pondicherry, Tamil Nadu,
Manipur, Nagaland, Mizoram,
Sikkim, Arunachal Pradesh, Assam,
Tripura, Meghalaya

6. Financial management under RNTCP


Financial management is done through State and District health Societies.
(A) State Health Society (SHS)

Functions
1. Societies have been formed to give autonomy in financial matters and to provide greater
discretion, enhanced responsibility, and more ownership to the states. Societies
undertake activities through bottom-up approach in planning and budgeting process,
i.e. from DHS (TB)-SHS (TB)-CTD and flow and release of funds from top down
approach from CTD-SHS-STDC/DHS.
122

Training Course for Program Manager


2. Responsibility for releasing funds to DHS in the state, monitoring of expenditures, audit
reports and providing statement of expenditures to CTD.
3. Ensuring the effectiveness of functions including monitoring and supervision of the
district activities, conducting review meetings, managing drug stocks and doing financial
management.
(B) District Health Society (DHS)

Functions
The main objective of the District Health Societies (DHS) is to implement the RNTCP
functionally, administratively as well as financially. The government has established the
DHS for the following reasons:
1. Decentralized implementation of the programme
2. Improving co-ordination between the government functionaries and non-government
organizations at the grass root level
3. Timely preparation of audit reports
4. Reducing bottlenecks for smooth flow of funds
The financial activities of the DHS cover the following areas:
1. Obtaining funds, and materials from the State Governments / Societies
2. Ensuring that the funds, equipment and materials are recorded properly in the books of
accounts as per statutory and generally accepted norms and that the same are being
utilized appropriately.
3. Reporting to the Central and State Governments on financial performance according to
the guidelines specified by the Government of India.
(C) Maintenance of Funds of the SHS/DHS
1. A separate saving bank sub-account has to be opened and maintained in any scheduled
banks for RNTCP sub-committee.
2. All funds credited to the society shall be deposited in the bank.
3. Withdrawal from funds including all payments shall be made through crossed cheques/
bank drafts.
4. All cheque shall be signed by any two of the three authorized signatories.
5. Unspent balance after closure of the financial year may be carried forward to the next
financial year.
(D) Mechanism of flow of funds
1. The Government of India (GoI) will make allocation of funds to the SHS on the basis of
plan of action/ budget of the SHS and DHS.
2. The SHS should prepare and submit budget to the CTD by 31st October for the next
financial year.
3. On submission of SOEs (DHS and SHS) by the SHS in April/October, the first and
second release will be made in May/November by the GoI.
4. SHS allocates and releases funds to DHS depending upon their individual performance
and requirement on quarterly/six-monthly basis
5. Timely reallocation of funds as per financial guidelines.
(E) Basic Fundamentals for Preparation of Budget
1. Standard norms and guidelines prescribed by CTD should be strictly adhered to.
123

Training Course for Program Manager


2. Budget should be prepared for each head for each district, STDC and STC, keeping in
consideration the actual requirement and realistic expenditure to be incurred by them
and not merely on eligibility criteria.
3. Budget must be prepared for financial year, i.e. from 1st April (current year) to 31st March
(next year).
4. DHS can reallocate revised budget up to 15% of recipient budget head. If requirement
still exceeds, approval of SHS must be obtained.
5. SHS can reallocate revised budget up to 100% of the recipient budget head without any
prior approval from CTD.
(F) Standard Norms and Guidelines for Preparation of Budget:
Please see Annexure I.
(G) Other key points:
1. Budget requirements under a particular head for the year should be calculated after
taking into consideration the balance from previous year.
2. In case funds are lying unutilized under specific head/s, the same may be reallocated to
the other head/s where utilization rate of funds is high. The exercise may be carried out
for all districts ensuring that the balance available under respective heads for each
district is not more than the 6-month requirement for the district. The amount to be
reallocated to a particular head should be calculated after taking into consideration the
amount already released under the head for the district so that the total funds available
in the current financial year are not more than the eligible amount for the year for the
receiving head.
3. Reallocation up to 100% of the eligible amount of the receiving head is permitted at the
State level. For any reallocation exceeding this limit, prior permission of CTD must be
obtained.
4. Hiring of Contractual Staff: The State is permitted to hire the following staff on
Contractual basis at ;
A. State level:
a. One Asst. Program officer/ Epidemiologist, Medical Officer (for STC), Accountant,
IEC Officer, Communication Facilitator, Secretarial Assistant, DEO, Driver at
State TB Cell,
b. One Microbiologist, Sr Lab Technician and DEO at IRL
c. DOT Plus site Sr. Medical Officer, DOT Plus site Statistical Assistant, for every
DOTS puls, TB-HIV Coordinator (MO), Urban TB Coordinator (MO) wherever
sanctioned by CTD
d. One Pharmacist/ Store Keeper, Store Assistant at State Drug store
B. District level :
a. One DEO, Driver and Part-time Accountant, Supervisor for TB-HIV & DOTS-Plus
at District TB Centre
b. One STS and one STLS for each TU
c. Up to 20% of all LTs at DMCs of the State as a whole, after considering the
number of available trained LTs and after obtaining permission from SHS
d. Up to one TBHV for every 1 lakh urban population after obtaining permission
from SHS
124

Training Course for Program Manager


e. Up to 15% of Second MO at DTC after obtaining permission from SHS.
( TOR of these positions are given in Annexure to Module I.)
5. TA/DA for contractual staff is to be paid from the miscellaneous head as per Revised
Financial norms (Reference Annexure I, Para 16).
6. Procurement: Vehicles and equipment are to be purchased following RNTCP financial
norms and procurement guidelines. (Abbreviated procurement guidelines enclosed as
Annexure II.)
7. Equipment Maintenance: Financial norms for equipment maintenance includes provision
for upgradation of Computers, Internet Connectivity, softwares (e.g. Anti-virus) and the
annual maintenance contract for Binocular Microscopes and equipments at Intermediate
Reference Laboratory.
8. Research: The state will provide technical and financial support for undertaking
operational research by STDC/ Medical Colleges/ other institutes as per the RNTCP
operational research guidelines ( Guidelines available on website ). The funds will be
released by the state/ DHS on approval of the research proposal by the respective OR
Committee ( state/ zonal/ central ) in accordance with the RNTCP OR Guidelines.
9. All books of accounts and records listed in the RNTCP Financial Management Manual
(FMM) need to be maintained by the SHSs & DHSs on an up to date basis and in the
appropriate formats suggested for the purpose.
10. The DHSs & SHSs to submit SOEs, Audit Reports and UCs as per the time-lines laid
down in the FMM, not only for timely release of funds to States but also to prefer
reimbursement claims in time from the funding agencies by CTD.
11. DHSs and SHSs to strictly follow the Internal Control and Internal Review mechanisms
laid down in the FMM.
12. All DHSs and SHS to strictly follow the procurement procedures laid down in the
Procurement Manual. ( Abbreviated procurement guidelines enclosed as Annexure II.)
13. For the purpose of fund allocation, the States have been classified in terms of size as
below:
a. Large State Population > 30 million.
b. Medium State Population between 10 and 30 million.
c. Small State Population less than 10 million.

125

Training Course for Program Manager

1. NATIONAL RURAL HEALTH MISSION (NRHM)


Health Care Infrastructure in India
The Primary Health Care infrastructure has been developed as a three tier system with
Sub-Center (SC), Primary Health Center (PHC) and Community Health Center (CHC) as its
three pillars.
The primary health centers which provide the initial point of contact, have basic medical
services (including for TB), and have referral linkages for specialized care with the
secondary and tertiary levels. To tide over variations in individual states capacity (health
being a state subject), priority health issues including maternal and child health
interventions, TB treatment etc are being supported as Centrally Sponsored Schemes
(national health programmes), and delivered through the public health care delivery system.
NRHM- A Partnership for Meeting Peoples Health Needs
To fulfill every individuals right to access basic health care services, the existing primary
health care system required restructuring and strengthening to make it more functional,
efficient and accountable. Substantial investments were required to strengthen, upgrade
and expand the public health infrastructure to enable them to conform with norms and
standards.
Launched in 2005, the National Rural Health Mission (2005-12) seeks to provide effective
healthcare to rural population throughout the country with special focus on 18 states, which
have weak public health indicators and/or weak infrastructure. The Mission is an articulation
of the commitment of the Government to increase public spending on Health from 0.9% to
2-3% of GDP.
Under NRHM, the difficult areas with unsatisfactory health indicators were classified as
special focus states to ensure the desired attention for these areas. The thrust of the
mission is to establish a fully functional, community owned, decentralized health delivery
system with inter-sectoral convergence at all levels, to ensure simultaneous action on wide
range of determinants of health like water, sanitation, education, nutrition, social and
gender equality. Institutional integration with fragmented health sector is expected to
provide focus on outcomes, measured against the Indian Public Health Standards (IPHS)
for all health facilities. The focus is on functional health system at all levels, village to
district. In this process, the Mission would help achieve goals set under the National Health
Policy and the Millennium Development Goals. This large scale investment into the health
system would have positive ripple effects on the overall functioning of the health system
and the disease specific interventions, including TB. The TB programme, being a part of
NRHM, will utilize these resources to strengthen TB care and control activities.
Health is a state subject and NRHM is an effort at building a partnership with the states to
ensure meaningful reforms with more resources.
Key NRHM Strategies:
The Accredited Social Health Activists (ASHA) programme is one major component of
NRHM. Every village/large habitat will have a female ASHA chosen and accountable to the
panchayat to act as the interface between the community and the public health system.
ASHA would act as a bridge between the Auxillary Nurse Midwife (ANM) and the village
and accountable to the Panchayat. She will be an honorary volunteer, receiving
126

Training Course for Program Manager


performance-based compensation for promoting universal immunisation, referral and escort
services for Reproductive and Child Health (RCH), provision of DOT, helping in initial home
visits, default retrieval, construction of household toilets, and other healthcare delivery
programmes.
Provision of untied funds and flexible financing is another component at all levels, from sub
center to district hospital, empowering local health care providers and addressing many
critical gaps in service delivery. By forming registered societies at PHCs, CHCs and district
hospitals, legal entities are created that have greater flexibility in discharge of their
functions. Rate of utilization of these funds is increasing each year.
Key strategies under NRHM:

Formation of Hospital Development Societies (Rogi Kalyan Samiti) in states with


provision of untied funds to them for enabling facility development.
Involvement of Panchayat standing committees members in District Health and
Family Welfare Societies, Rogi Kalyan Samiti (RKS), the Village Health and
Sanitation Committee (VHSC) and selection of ASHAs.
Indian Public Health Standards (IPHS) formulated as valuable benchmark for
facilitating states to reach desirable levels of both infrastructure and human
resource. This has lead to filling up of existing posts and creation of new posts. Multiskilling of the nurses and medical officers for specialist tasks is additional strategy
taken up by few states.
Setting up of an integrated State and District Health Societies with representation
from all programme divisions on financial management, monitoring and use of
human resources.
Decentralized district level planning through preparation of District Health Action
Plans, which bring together the specific health needs of the people and the district
information making a basic skeleton of the state plan. RNTCP district action plan is
a part of this plan.
Setting up of district and state Programme Management Units (PMUs): To
strengthen capacities for data collection, assessment and review for evidence based
planning, monitoring and supervision, for strengthening management systems,
finance management, logistic/procurement and infrastructure systems and inculcate
management skills in health team for the techno-managerial role to be played by the
respective district programme officers, provision of Programme Management Units
(PMUS) for all districts through recruitment of contractual Master in Business
Administration (MBA), Chartered Accountants (CA), Masters in Computer
Application (MCA) & Data Entry Operators (DEO) has been made.
Improvement in Financial management procedures with the use of e-transfer for
funds upto districts and induction of personnel with financial management skills.

The National Rural Health Mission is a mechanism which has provided an umbrella in all
states with the repositioning of Reproductive and Child Health (RCH) and National Disease
Control Programmes in integrated State/District Health Societies.
TB related objective of the Mission is Prevention and control of communicable and
non-communicable diseases, including locally endemic diseases with expected
outcome of maintaining 85% cure rate through entire Mission period and also sustain
planned case detection rate .
127

Training Course for Program Manager


With the additional resources being pooled in the structural and human resource, deficits
are expected to be met, as TB control strategy with its critical components {like laboratories,
drug stores, Laboratory Technicians (LTs)} have been incorporated as part of the Public
Health Standards established for each level of health institution. In addition, ASHA workers
would also facilitate enhanced outreach activities. The Mission envisages to fill in the gap in
the existing programmes with respect to infrastructure and service delivery through
Additionalities under NRHM.
RNTCP is a centrally sponsored scheme under NRHM, and fund flow for programme
activities is taken up through State and District Health Societies (earlier through the State
TB Control Societies, District TB Control Societies /Municipal TB Control Societies which
have now been integrated as Health societies under NRHM). The Health Societies are
special purpose vehicles for receipt of funds from the Ministry of Health and Family Welfare
and implementation of the project activities within the concerned State/ District/ Municipal
Corporation.
Under the mission, in order to reflect the requirements of the state in a consolidated
Programme Implementation Plan (PIP), the states need to incorporate various TB
control activities and budget it in Part D of the PIP which is subsequently reviewed by
Central TB division during the appraisals of the PIP. The existing District Annual Action
Plan/ State Annual Action Plan formats of RNTCP have to be incorporated in the NRHM
State PIP.
RNTCP is implemented through the general health system. The overall responsibility of
implementing RNTCP activities rests with the staff under general health services.
Flow of Funds for RNTCP under NRHM:
The funding for RNTCP-II is done from the budget of the Ministry of Health & Family
Welfare. The annual budget of the project would be allocated as per the National PIP and
Annual Action Plan submitted by the state. The CTD shall release these funds to the State
Health Society on a half yearly basis. Under NRHM the funds would flow into the respective
programme specific sub-account of the group account. Therefore the funds for RNTCP will
be in a separate individual sub account.
Under NRHM the Finance Management Group (FMG) maintains a centralized data base of
releases and utilizations under NRHM i.e. RCH, additionalities under NRHM, Immunization
and National Programmes i.e. RNTCP, NVBDCP, other NDCPs etc.
Appointment of Auditors under NRHM:
As per the financial guidelines of NRHM single auditor will be appointed for all the
programmes under NRHM at SHS and DHS level and a chapter on RNTCP will be
submitted separately. This is to ensure timely disbursements and submission of audit
reports to the donor agencies.
8. RNTCP NACP coordination
The overall goal is reduction in TB related morbidity in people living with HIV/AIDS while
preventing further spread of TB and HIV through collaboration between RNTCP and NACP.

128

Training Course for Program Manager


Objectives:
To establish and strengthen the mechanisms for coordination between RNTCP and
NACP at National, State and District levels.
To decrease morbidity and mortality due to tuberculosis among persons living with
HIV/AIDS.
To decrease the impact of HIV in tuberculosis patients and provide access to HIV
related care and support to HIV-infected TB patients.
Key activities include:
1. Establish and Strengthen NACP-RNTCP co-ordination mechanisms at national state
and district level.
2. Scaling up of Intensified TB-HIV Package of Services across the country.
3. Joint Monitoring and Evaluation including standardized reporting shared between the
two programmes.
4. Training of the programme and field staff on TB-HIV
5. TB and HIV service delivery coordination
5.1. Offer HIV testing to all TB patients
5.2. Intensified TB case finding at ICTCs, ART, and Community Care Centres
5.3. Linking of HIV-infected TB patients to HIV care and support ( including antiretroviral
treatment) and to RNTCP for TB treatment
5.4. Provision of cotrimoxazole preventive therapy (CPT) for HIV-infected TB patients
6. Implementation of feasible and effective infection control measures
7. Involvement of NGOs/Community based organizations (CBOs) and affected
communities working with NACP and RNTCP for all activities on TB-HIV collaboration.
8. Operational research to improve the implementation and impact of TB-HIV collaborative
activities.

NACP-RNTCP coordination mechanisms at National, State and District


level
I.

National Technical Working Group (TWG)


At the National level a technical working group is in place, comprising of key officials
from NACO and CTD dealing with TB-HIV Collaborative activities and experts from
WHO. The purpose of the TWG, which meets at least quarterly, is to review,
optimize and plan for future TB-HIV Coordination activities. The function of National
TWG also includes supervision of TB-HIV collaborative activities by officials of both
programmes, including joint field visits.

II.

State Level:
A. State Coordination Committees
To ensure smooth implementation and regular review of TB-HIV Collaborative
activities, State Coordination committees (SCC) chaired by Principal Health
Secretary and with representations of state programme managers of both
programmes are established at the State level. These coordination committees meet
at-least once in 6 months, preferably once in a quarter. The detailed composition and
proposed TOR of State Coordination Committees is described in the National
Framework for Joint TB/HIV collaborative activities October 2009 may be accessed
from website. The SCC can be used to obtain administrative approvals for the TBHIV activities guided by the STWG recommendations. Minutes of quarterly State
129

Training Course for Program Manager


Coordination Committee meetings should be sent to NACO and CTD at
tbhiv@rntcp.org.
B. State Working Group (SWG)
The State Working Group is composed of key officials from State Aids Control
Society (SACS) -Project Director and Additional Project Director and State TB Cell STO, second MO if present, along with other officials dealing with TB-HIV
collaborative activities and consultants involved in HIV-TB collaborative activities.
The SWG would review and streamline the collaborative activities. In these quarterly
meetings of SWG, apart from a review of the on-going TB-HIV collaborative
activities, the key issues emerging from the district coordination meetings and
reports are to be discussed. Based on the discussions, feedback should be sent to
the districts on their performance and identified issues. Follow up action taken
should be monitored and minutes of the meetings forwarded to NACO and CTD at
tbhiv@rntcp.org.
III.

District level
A. District Coordination Committees
To ensure smooth implementation and regular review of TB-HIV Collaborative
activities, Coordination committees are established at the District level. These
coordination committees are to meet on a quarterly basis. The composition and
proposed TOR of District Coordination Committees is described in the National
Framework for Joint TB/HIV collaborative activities October 2009 and may be
accessed from website. These meetings are to be organized by District Nodal
officers (DNO) for HIV/AIDS or DTOs where DNOs are not available. Minutes of
district quarterly meetings should be sent to SACS and State TB Cell. Whenever
possible, the meetings should be attended by a representative from the STC/SACS
so as to streamline the discussions for the HIV-TB linkages and to raise the district
specific issues.
B.

Monthly meeting at the District level

A monthly meeting of the DTO and the District Nodal Officer (DNO) should be held
with the participation of key staff from both the programmes. Monthly meetings of the
key staff of RNTCP are to be conducted at the district level. It is envisaged that
during these monthly key staff meetings, additional session be organised for TB-HIV
which should be attended by the key district staff of NACP. In these monthly
meetings a review of the on-going TB-HIV collaborative activities and discussion on
key issues emerging from the field should be undertaken. Based on the discussions,
feedback should be sent to the service delivery centres on their performance and on
any identified issues. Follow-up action taken should be monitored and minutes of the
meetings forwarded to SACS and STC.
IV.

Annual Review of TB-HIV Collaborative activities at National and State level


RNTCP conducts regular programme reviews at the National and State levels. It is
planned that at one of these reviews at the National level, an annual review of the
TB-HIV Collaborative activities would be held with the participation of State
programme managers of both programmes. The annual review would be held in
close coordination between NACO and CTD.

130

Training Course for Program Manager


Similar annual reviews would be held at the State level by adding an additional day
to one of the quarterly RNTCP review meetings and inviting the district Nodal officers
for HIV/AIDS and SACS officials. These State level reviews are to be organised in
coordination with SACS and STC. Whenever possible representatives from CTD and
NACO would be attending these State reviews.
V.

Human Resources for TB-HIV collaborative activities


To facilitate coordination and successful implementation of TB-HIV collaborative
activities, the following positions have been sanctioned:
A. A full-time regular government officer would be in charge of TB-HIV Collaborative
activities in the programmes at the National and State level in NACP and
RNTCP.
B. National Consultants for TB-HIV (NACP & RNTCP)
C. Technical officers at SACS for Basic Services (including TB-HIV) are available
across the country (1-2 per state).
D. TB-HIV Coordinators have been sanctioned by RNTCP in 15 States (Assam,
Bihar, Chhattisgarh, Delhi, Gujarat, Himachal Pradesh, Jharkhand, Kerala,
Madhya Pradesh, Orissa, Punjab, Rajasthan, Uttar Pradesh, Uttaranchal and
West Bengal)
E. District level: A new district level supervisory position TB-HIV and DOTS-Plus
supervisor has been sanctioned.

Intensified TB-HIV Package of Services


The package is designed to enhance identification of HIV-infected TB cases, link to HIV
care and support and monitoring of TB-HIV collaborative activities. The table below
highlights the additional activities which have been included under the Intensified TB-HIV
package.
Core TB-HIV activities for all settings
District and State-Level Coordination
between NACP and RNTCP
Training of programme officials and field
staff on TB-HIV
Intensified TB Case Finding at all ICTCs,
ART Centres, and Community Care Centres
Referral of HIV-infected TB patients to
additional care and support for HIV,
including cotrimoxazole prophylactic
treatment and antiretroviral treatment
Referral of TB patients for HIV-testing based
on HIV risk factors (selective referral)
Core TB-HIV recording and reporting from
NACO MIS and RNTCP (PMR)

Intensified TB-HIV Package States


District and State-Level Coordination
between NACP and RNTCP
Addition: Extra training on Intensified TB-HIV
package for programme and field staff
Intensified TB Case Finding at all ICTCs,
ART Centres, and Community Care Centres
Addition: Decentralized provision of
cotrimoxazole prophylactic treatment (CPT)
to HIV-infected TB patients from all
peripheral health institution
Addition: Routine referral of all TB patients
for voluntary HIV- counselling and testing
ICTC
Addition: Expanded TB-HIV recording and
reporting by RNTCP (CF and RT reports)

The expansion of the Intensified TB-HIV package to additional States would be undertaken
in a phased manner, jointly determined by the National Programmes. A tool for assessment
for preparedness for rolling out the Intensified TB-HIV package is provided in the National
Framework for Joint TB/HIV collaborative activities October 2009 and may be accessed
from website. The SACS & STC need to jointly provide information on the tool which would
131

Training Course for Program Manager


be reviewed at the National level and states would be provided feedback on the level of
preparedness and starting the intensified package as jointly determined by the national
programmes.
TB and HIV service delivery coordination
Intensified TB case finding at ICTCs, ART, and Community Care Centres
Screening for symptoms and signs of TB in places where HIV-infected people are
concentrated, followed by diagnosis and prompt treatment, increases chances of survival,
improves quality of life, and reduces transmission. Intensified TB case finding should be
established in ICTCs, ART Centre, CCCs and among household contacts of those known to
be infected with TB.
HIV testing of TB patients
In states implementing Intensified TB-HIV Package, the policy of routine offer of HIV
counselling and voluntary testing to all TB patients at ICTC has been adopted. This referral
should be done as soon as possible after diagnosis, and results should be communicated
back to the referring provider in order to provide better patient management.
Eventually all the states would be covered under the Intensified Package. In settings not yet
implementing the intensified package, Medical Officers should conduct an appropriate and
detailed clinical history on all TB patients to determine the need for HIV testing. All TB
patients with a history of any high risk behavior, with a history of present or past STI, or any
clinical signs/symptoms suggestive of HIV-related opportunistic infections should be
referred to an ICTC for counselling and HIV testing.
Referral of HIV-infected TB patients to NACP for care and support, including ART
The treatment of HIV-infected TB persons should be done using RNTCP DOTS as per
national policy. All known HIV-positive TB patients are considered seriously ill regardless of
sputum smear results, and are offered either RNTCP treatment regimen for new cases or
previously treated cases, depending on their previous history of TB treatment.
In addition to TB treatment under RNTCP, all HIV-infected TB patients must be provided
access to care and support for HIV/AIDS, including ART. ART reduces TB case fatality
rates and the risk of recurrent TB. ICTC counsellors and the treating physicians should
counsel these patients on the importance of ART and on the free availability of evaluation
for ART and treatment.
HIV-infected TB patients should be promptly referred to the nearest ART centre by the
treating physicians and ICTC counsellors. This visit to the ART centre, however, should
preferably occur at least two weeks after initiation of TB treatment, to ensure that at least
some reduction in TB transmission potential among these patients prior to visit in a clinical
setting with large numbers of HIV-infected persons. TB patients referred to ART centres
should be carefully educated on cough hygiene.
For details on ART eligibility, refer ART guidelines available at www.nacoonline.org.
NACO recommends that ART be given to:

All patients with extrapulmonary TB (stage 4)


All those with pulmonary TB (stage 3) with CD4 count is < 350 cells/mm3.
132

Training Course for Program Manager

Provision of cotrimoxazole preventative treatment (CPT) for HIV-infected TB patients

CPT has been shown to reduce mortality among HIV-infected TB patients, and is
recommended by NACP for all HIV-infected patients.
All HIV-infected TB patients should therefore be provided CPT. At a minimum, monthly
provision of CPT should be available at all ART centres for the benefit of those patients who
are able to return to the ART centre on a monthly basis.
In States implementing Intensified TB/HIV package, CPT should also be made available for
HIV-infected TB patients at all PHIs in the districts having a Medical officer and an
institutional DOT centre, using RNTCP mechanisms. The delivery of CPT to all HIV infected
patients after completion of DOTS will be made from ART Centre. The CPT should be
procured and packed into monthly pouches by SACS and the local distribution should be
carried out by RNTCP in coordination with NACP. In this mechanism, CPT is delivered by
the PHI staff, and not community DOT providers, to maintain confidentiality regarding HIV
status within the health-care system.
Guidelines for Operationalization of ICTC-RNTCP Linkages
Service linkages between ICTC and RNTCP diagnostic and treatment centres are the most
important area of co-ordination between the HIV/AIDS and TB Control programme. RNTCP
visualizes ICTC as a PHI referring TB suspects irrespective of their HIV-status. ICTCs will
identify and refer suspected TB cases to the RNTCP Designated Microscopy Centres
(DMCs). DMCs/ OPD/ wards may refer TB patients for counselling and diagnosis of HIV
infection. They could also refer known HIV positive TB patients to the ICTC for
Counselling.
A. Steps for Operationalization

Ensure that the ICTC, DMC and DOT centre are in the same campus. In case they
are not in the same campus, establish referral linkages between them
Ensure that all the ICTC and RNTCP staff, including the LT of the DMCs and ICTC,
are trained in TB/HIV
Provide RNTCP Laboratory Forms for sputum examination/sputum cups, for referral
of patients from ICTC to DMCs under RNTCP
Provide a DMC and DOT centres directory to all the ICTCs
Ensure display of posters on TB at the ICTCs and provide other related IEC material
on TB that is available for distribution to clients
It is ensured that shared confidentiality of HIV status is maintained between the
treating physician and the patient. HIV status is mentioned in the original treatment
card and in the TB registered.
The ICTC Counselors are to visit the DMCs, and the STSs are to visit the ICTCs to
follow-up referred cases.
Monthly RNTCP Review meetings are to be attended by the ICTC staff.
State TB Officer, State ICTC Programme Officer, District TB Officer and District
Nodal Officers (HIV/AIDS) are to review TB/HIV co-ordination activities during their
periodic field visits.

133

Training Course for Program Manager


B. Referral from ICTC to RNTCP (Diagram 1)
i. The Process at ICTC
ICTC Counselors will identify persons with symptoms suggestive of TB disease
amongst the clients. The Counselor will elicit history of cough for more than two
weeks and other associated symptoms of TB from each and every client. These
patients, depending on their symptoms will be referred for appropriate investigation.
Patients, irrespective of their HIV status, having cough will be referred to DMC for
sputum examinations and in case of symptoms of extra pulmonary TB, the patient
should be referred to the appropriate specialist. The request for sputum examination
form will be filled in by the Counsellor. On the sputum examination form, the
Counselor should fill all the required details including the name of ICTC, and ensure
special care in obtaining and recording correct residential address. The counselor
will not mention the HIV status of patient on the form or elsewhere, but shall
encourage the patient to disclose his HIV status (if known) to the treating physician,
in the interest of better treatment management. The sputum examination form is
given to the patient with specific instructions on the location and timings of the DMC.
The Counselor should make a detailed note of the referral in the Counselling
Register.
The counselor should impart information on TB to all ICTC clients and should
document the same in the counselling register, irrespective of whether they have
signs or symptoms of TB or not. Either a column can be added in the Counselling
register to document the information on persons who received information /
counselling on TB or record it in the Remarks column of Counselling Register.
During counselling, encourage voluntary disclosure of HIV status by the client to the
treating physician in those referred.
ii. The Process at Designated Microscopy Centre (DMC)
Once the patient reaches the Designated Microscopy Centre, the patient will
undergo the same process as any other TB suspect, i.e. the diagnostic algorithm of
RNTCP will be followed. The Laboratory Technician will enter the details of the
patient, including correct residential address, in the TB Laboratory Register and
clearly mention the name of ICTC as the referring unit in TB laboratory register.
After all the two sputum examinations are done, the results of the test are given to
the patient. Patient will go to the Medical Officer, who will decide on further
management.
In case of Extra-pulmonary TB, the ICTC will refer the patient to the Medical Officer,
who will further refer the patient for necessary investigations. After obtaining the test
results, the Medical Officer will decide upon further course of management.
If the patient is having TB (Pulmonary or Extrapulmonary TB), treatment allocation is
done as per the RNTCP treatment algorithm. Known HIV positive cases, diagnosed
with TB disease for the first time (new TB cases) will receive RNTCP treatment
regimen for new cases whereas retreatment TB cases will receive treatment regimen
for previously treated cases. Voluntary disclosure of the HIV status by the client
should be encouraged. Based on patients area of residence, these patients are
referred for treatment to the nearest DOT centre. A home visit is undertaken done to
134

Training Course for Program Manager


confirm the patients address. Once the address verification is over and the patient is
convinced to take DOTS for the required duration, the treatment is started. Patients
treatment card is prepared. Once the patient is started on treatment, the Senior
Treatment Supervisor (STS) will enter the patients information in the TB register and
give a TB number, which is mentioned in the treatment card. In cases of referral for
treatment to another district / TU, special care must be taken to obtain feedback
from the receiving district / TU about initiation of the treatment. STS and ICTC
counsellor will coordinate to check how many of the referred patients did reach DMC
and record the outcome of the referral.
iii.

Recording information on TB status of persons referred by ICTC


If the patient returns to ICTC after attending the DMC, the information regarding the
diagnosis should be recorded in to the Counselling Register. For the remaining
patients, at the end of the next month, when the information about the TB suspects
referred from ICTC is provided in the Line-List by STS, this information is transferred
onto the Counselling Register.

Line-List of Persons Referred From ICTC TO RNTCP


The Line-List (Annex-II) is prepared for each ICTC in the district separately. On the LineList, the name of the ICTC, the district and the reporting month/year is to be filled in by the
ICTC counselor. The Line List has two parts. Part A, i.e. columns 1 to 7 contains
information on the persons referred by ICTC to RNTCP. Part A is to be completed by the
ICTC Counselors and signed by the ICTC Counselors and the In-charge of ICTC. Below the
signature, date of completion of Part A is to be mentioned. Note that only those persons
who have been sent from ICTC to RNTCP are included here.
a) PART A of LINE-LIST
COLUMN COLUMN
NO.
TITLE
1

Sr. No.

PID No.

Complete Name
and Complete
Address

4
5

Age
Sex

Date of Referral

Name of
RNTCP Unit
referred to

WHAT SHOULD BE WRITTEN


This is the serial number that you will write as you are
making the line-list
PID No. (Person Identification Digit No) is the number
that the ICTC Counsellor has given to the client.
It is important to have the complete name and
address of the person, otherwise it is difficult to trace
out whether these persons have reached RNTCP
Unit, whether they have been investigated and put on
treatment. Therefore the ICTC Counsellor should
write the complete name of the person. The telephone
number of the client may be mentioned if available
Age of the person should be mentioned
Male, Female or Transgender should be mentioned
The date when the client is referred to the RNTCP
Unit
RNTCP Unit includes DTC, DMC, TB OPD, TB Clinic
etc i.e., any health facility where the facility for sputum
investigation for TB under RNTCP is available. In
case the patient is referred to a doctor/OPD, the name
of the OPD should be mentioned.
135

Training Course for Program Manager


For sputum examination, the counsellor should
identify the Microscopy Centre that is convenient for
the patient.
The Counsellor should record the name of the centre
the person has been referred to.
The Counsellor will meet the STS with the line list on the 1st or 2nd of the next month,
i.e., the Line List for patients referred in the month of January, will be completed
(Columns 1-7) in the first week of February by the Counsellors and handed over to the
STS.
The STS/STLS will scan through the TB laboratory register to find out whether these
patients have undergone the sputum microscopic examination. If the patient is sputumpositive, then the TB number as mentioned in TB laboratory register will tell whether the
patient has been started on DOTS and the treatment category. If the patient is sputumnegative, then look for the patient in the TB register of the concerned Tuberculosis Unit.
If patient was suspected of having Extrapulmonary TB, referring to the TB register would
be helpful. For diagnosed TB patients referred out for DOTS treatment to another TU,
the STS of the corresponding TU should be consulted, and for referrals for treatment
outside the District the referral for treatment register at the DMC should be scrutinized.
Once the Line-List is completed (Columns 8-13), the STS will sign the list and write the
date of completion of Line-List. The STS will then take the signature of the concerned
DTO/CTO or MO-TC. This Line List is handed over to the ICTC Counsellor by the fifth of
the month.
b) Part B of LINE-LIST
COLUMN
NO.

COLUMN TITLE

WHAT SHOULD BE WRITTEN

Is patient
diagnosed as TB
Yes or No

If the patient is diagnosed as TB mention YES


and if non-TB mention NO. For getting this
information, the STS will need to check the TB
Laboratory Register, Treatment Referral
Register and the TB Registers

If diagnosed as TB,
specify whether
patient is sputumpositive TB,
sputum-negative
TB or Extra
pulmonary TB

If the patient is diagnosed as TB, the STS


should mention whether the patient is sputumpositive TB, sputum-negative TB or extra
pulmonary TB.

Is patient initiated
on DOTS Yes/No

Once diagnosed, the patient should be started


on treatment. From the TB register, find out
whether the patient is receiving RNTCP DOTS.
Mention Yes if patient is being treated under
RNTCP DOTS regimen and No if under any
other regimen

10

136

Training Course for Program Manager


11

Date of Starting
Treatment

12

TB No.

13

Remarks

The date of starting treatment as mentioned in


the TB register should be recorded in the LineList.
From the TB register, write the TB number
The following information can be entered in the
remarks column.
- Name of the DOT centre to which Patient has
been referred to- Name of the district, if the
patient is from another district
- If the patient has not reached DMC, it may be
mentioned here
- If patient has died, date when expired
- Reason for placing the patient on Non-DOTS
regimen
- If patient is from the district and has not been
started on treatment, mention the reason.
- any other

c) Monthly TB/HIV Report, integrated into MIS


ICTC-RNTCP co-ordination is monitored with the help of the monthly report on
TB/HIV activities. In order to prepare the monthly report, the first step will be to
make the Line-List. Preparing the LineList will be the joint responsibility of the ICTC
and RNTCP. Patients who are referred by MO-PHI to ICTC and DMC simultaneously
are not to be included in the line list and the monthly report. The Line List for patients
referred in the month of January, will be completed in the first week of March (5th of
the month) by the Counselors and STS. Once the Line-List is completed, the monthly
report will be prepared by the ICTC. The completed Line List and the Monthly Report
will be compiled and submitted by the ICTC to all the concerned Officials (State
AIDS Control Society, DTO, DAPCU Officer /DNO (HIV/AIDS)). The time taken for
diagnosis and initiation of TB treatment may take up to 7 days and registering the
patient in the TB register may take another few days and a maximum up to 1 month.
Therefore, there will be a delay of one month in reporting of TB/HIV cross-referral. It
means that the report of January will be submitted in March, that of February in April
and so on.
Section I: TOTAL NUMBER OF CLIENTS ATTENDING ICTC:
INDICATOR
a) Total no. of clients
who attended ICTC
in
the
month
(excluding PPTCT
Clients)

WHAT SHOULD BE WRITTEN


Refer to the Counselling Register and count the number of clients
who have received pre-test counselling for the month. The
reporting period is from day one of the month to the last day of
the month. Dont include the PPTCT clients.

137

Training Course for Program Manager


Section II: REFERRAL OF SUSPECTED TUBERCULOSIS CASES FROM ICTC TO
RNTCP
INDICATOR
a) No. of persons
suspected to have
TB referred to
RNTCP Unit

b) of the referred
TB suspects, No.
diagnosed
as
having:
(i) Sputum-positive
TB
(ii)
Sputumnegative TB

(iii)
ExtraPulmonary TB

c) Out of above
(b), diagnosed TB
patients, number
receiving DOTS

WHAT SHOULD BE WRITTEN


From the Line-List count the total number of persons suspected to
have TB who were referred to RNTCP Unit. Referring to the
Counselling register, count how many of these persons are HIV
sero-positive and how many are HIV sero-negative. Mention
accordingly under the appropriate columns in the monthly report.
In case the person has not undergone HIV test, but still has been
referred to RNTCP he will not be included in this indicator even
though his name is there in the line-list. Similarly in case of
indeterminate HIV test results, the person will not be counted.
Out of the HIV sero-positive TB patients count the number of
sputum-positive TB.
Out of the HIV sero-negative TB patients count the number of
sputum-positive TB.
The information on whether the person is diagnosed as sputumpositive TB is available from column no. 9 of the Line-List.
Out of the HIV sero-positive TB patients count the number of
sputum-negative TB.
Out of the HIV sero-negative TB patients count the number of
sputum-negative TB.
The information on whether the person is diagnosed as sputumnegative TB is available from column no. 9 of the Line-List.
Out of the HIV sero-positive TB patients count the number of
extrapulmonary TB.
Out of the HIV sero-negative TB patients count the number of
extrapulmonary TB.
The information on whether the person is diagnosed as
Extrapulmonary TB is available from column no. 9 of the Line-List.
Out of the HIV sero-positive TB patients count the number of
persons receiving DOTS.
Out of the HIV sero-negative TB patients count the number of
persons receiving DOTS
Include only those persons who are being treated with DOTS
Referring to column no. 10 of the Line-List will give this
information.

Section III: REFERRAL OF DIAGNOSED TB PATIENTS FROM RNTCP TO ICTC


INDICATOR
a) No. of RNTCP
registered
TB
patients tested for
HIV
b) Out of above (a),
No. detected to be
HIV Positive

WHAT SHOULD BE WRIITEN


Referring to the Counselling register, count the number of
persons who have been referred from RNTCP Unit. Among such
persons, count how many were tested for HIV
Among the RNTCP diagnosed TB patients (a), count the number
of persons who were found to be HIV positive out of

138

Training Course for Program Manager


PROCESS OF PREPARING THE MONTHLY REPORT:
The monthly report signed by the In-charge ICTC along with the duly completed Line-list
should be completed by the 5th/6th of the month and sent to District Nodal Officer for
HIV/AIDS, District TB Officer and the SACS office so as to reach latest by 10th of the month.
The District Nodal Officer for HIV/AIDS compiles the reports of all ICTC in the district
reports monthly to SACS.
ICTC Counsellor prepares part A of Line-List on 1st of the month.
(E.g. For January Report, Line List will be made on 1st February)

ICTC Counsellor takes the signature of I/C ICTC on 1st/2nd of the month.

STS completes part B of the Line-List 1st / 2nd of March.

STS takes signature of DTO/CTO/MO-TU by 3rd of the March

STS hands over completed Line-List to the ICTC Counsellor by 4th/5th


of the March.

Counsellor prepares the monthly report by the 5th/6th


of the March

Counsellor takes the I/C ICTCs signature on the monthly report by the 5th/6th
Process of Sending Monthly Report of the month
At District Level: The report will be sent by the ICTC to the District Nodal Officer for
HIV/AIDS, District TB Officer and the State AIDS Control Society. A copy the TB/HIV report
along with the line-list is given to the concerned District Tuberculosis Officer/City TB Officer.
The District Nodal Officer for HIV/AIDS compiles the reports of all ICTC in the district
reports monthly to SACS. The report should reach State AIDS Control Society by 10th of the
month.
At State Level: At the state level, at the SACS the information on TB/HIV activities will be
compiled and a centre-wise report along with the monthly report for the entire state will be
sent to NACO and CTD by the 15th of every month. A copy of this report will also be sent by
SACS to the State TB Office.
139

Training Course for Program Manager


C. Referral from ART Centre & CCCs to DMC under RNTCP:

The ART MO would directly refer the TB suspect to the DMC for sputum microscopy.
This would prevent unnecessary delay in diagnosis of TB and would minimize the
exposure of the HIV patient to other nosocomial infections.
The Lab. Technician would be instructed to collect the sputum sample of the patient
referred from the ART center on priority. The lab technician would be instructed to
mention ART center as the source of referral for such patients in the RNTCP lab
register. These measures would reduce the time spent by the HIV patient in the DMC.
The Lab technician would send the result of the sputum examination of the HIV positive
patient directly to the ART MO for diagnosis and allocation of treatment regimen.
The details regarding operationalization of ICF at ART Centres along with the line-list
and monthly report to be submitted is described in the TB/HIV module for ART centre
staff and may be accessed from www.tbcindia.org

D. Referral of TB Patients to ICTC for HIV-Testing


i.

Process at RNTCP Unit


Diagnosed TB patients who have symptoms/signs suggestive of HIV infection will be
referred by the medical officer to the ICTC. Thus, these diagnosed TB patients may
be referred from DMC, DOT Centre, Out-patient clinics, TB ward, TB Clinic etc.
Sometimes the patient may simultaneously be investigated for TB and HIV. The
doctor should first complete the investigations for TB and then refer for HIV
investigations. While referring to the ICTC, the doctor should write a referral note to
ICTC in which the TB status of the person is mentioned.

ii.

Process at ICTC
Once the referred TB patient reaches ICTC, the same procedure will be followed as
that for any other client attending ICTC. Some TB patients may come on their own
for HIV Testing (Direct Walk-In).
At the ICTC, the patient/client will undergo pre-test counselling. HIV testing is done
after obtaining informed consent. The details of the patient/client will be entered into
the PID register and Counselling Register. HIV testing is done and the test results
are handed over by the Laboratory Technician to the Counsellor. The counsellor
reveals the HIV test result to the patient/client with post-test counselling. The HIV
test results are not revealed to any other person other than the individual himself.
However, in states implementing Intensified TB/HIV Package HIV test results may be
shared with the treating Doctor.

140

Training Course for Program Manager


Diagram 1: Referrals from ICTCs to RNTCP diagnostic and DOT Centres
Integrated Counselling Testing Centre

Screen all Clients for symptoms of TB

Symptoms of Pulmonary
TB - Cough for more than
two weeks

No symptoms of
TB
Symptoms of Extrapulmonary
TB e.g. cervical
lymphadenopathy, etc.

Feedback
from STS
Fill in RNTCP
Lab form
DMC for Sputum
examination

Medical Officer

Appropriate
Investigation

Sputum
Results

Medical Officer RNTCP


Initiation of
appropriate treatment
regimen

DOT Centre

141

Clients go
back to
ICTC

PID
NO.

Complete Name &


Complete Address

Sign of Counsellor
Date of completion:

Sr.No.

Sex

7
Name
of
facility
referred
to

6
Date of
referral
to
RNTCP

YEAR

Sign of MO- ICTC

Age

TO BE COMPLETED BY ICTC COUNSELLOR


1
2
3
4
5

NAME OF DISTRICT:

REPORTING MONTH:

Name of the TU:


Signature of STS :
Date of Completion:

Date of
Starting
Treatment

11

TB
No.

12

Remarks

13

Signature of DTO/CTO/MO-TU

TO BE COMPLETED BY the STS


8
9
10
Is
If diagnosed
patient
as TB,
Is patient
initiated
specify
diagnosed
on
whether
as TB
DOTS
patient is S+
Yes or No
Yes or
TB, S- TB or
No
EP TB

NAME OF ICTC:

LINE-LIST OF PERSONS REFERRED FROM ICTC TO RNTCP

Training Course for Program Manager

ICTC TB-HIV Report

REPORTING MONTH: _______________

YEAR __________________

NAME OF ICTC:_____________________

DISTRICT:_______________

I. TOTAL NUMBER OF GENERAL CLIENTS ATTENDING ICTC:


a) Total no. of clients who attended ICTC in the month
(excluding PPTCT clients)

II.REFERRAL OF SUSPECTED TUBERCULOSIS CASES FROM ICTC TO RNTCP


HIV
positive
a) No. of persons suspected to have TB
referred to RNTCP diagnostic services
b) Of the referred TB suspects, No. diagnosed
as having:
(i) Sputum-positive TB
(ii) Sputum-negative TB
(iii) Extra-Pulmonary TB
c) Out of above (b), diagnosed TB patients,
number receiving DOTS

HIV
Negative

III. REFERRAL OF DIAGNOSED TB PATIENTS FROM RNTCP TO ICTC


a) No. of RNTCP registered TB patients tested for HIV
b) Out of above (a), No. detected to be HIV Positive
Signature of Medical Officer In charge ICTC
Name of Medical Officer In-charge ICTC

143

Training Course for Program Manager

Annexure -1A RNTCP


Format for Utilization Certificate to be Submitted by NGO/PP
UC for the Quarter.to..

Name of NGO/PP
Date of MoU
Name of District
Name of Scheme
Period of MoU

...............to.............

A. DETAILS OF GRANT-IN-AID RECEIVED

Half-yearly period for which


grant was given

Cheque dated

Cheque number

Amount (Rs.)

......to........
......to........

Total amount received

B. EXPENDITURE
Approved Budget as per MoU
Rs.

Total Grant
Received till this
Quarter
Rs.
a

This is to certify that Grant-in-aid


received from the
...(name
of the Society)
as per details mentioned above has
been utilized as per terms of
Memorandum of Understanding
dated......between
...(name
of NGO/PP) and the Society.
Name of Head of NGO/PP:
Signature of Head of NGO/PP:
Date:
Stamp:

144

Cumulative
Expenditure till
this Quarter
Rs.
b

Unspent
Balance
Rs.
c=a-b

Training Course for Program Manager


ACTION BY SOCIETY
by DTO/STO

Name of DTO/STO:
UC Received and Verified:
Signature of DTO/STO:
Date:

by Accountant

Checked UC :

Yes/ No

Entered information in NGO Payment and UC Register

Yes/ No

Updated Advance Register, if applicable

Yes/ No

Signature:
Date:

Annexure 1b Format for NGO/PP Payment and UC Monitoring Register


Name of NGO/PP
Name of Scheme
Period of Scheme
MOU dated

145

Cheque
number

Cumulative Exp. as
per UC
Rs.

Voucher
No.

Quarter 1 (to )

Date

Date UC Received

Rs.
a

Grantin-Aid
as per
MOU

Cumulative Exp. as
per UC
Rs.

Date UC
Received

Amount
Rs.

Cumulative Exp. as
per UC
Rs.

Quarter 3 (to )

Date

Cheque
number

Rs.

f= a - e

Unspent
Balance

d= b +c

Total
Released

Rs.

If
advance,
whether
entered
in
Advance
Register
(Yes/No)

Cumulative
Exp. as per UC
Rs.

Quarter 4 (to )
Date UC
Received

Advance/Reimbursement

Release for 2nd Half-year of MoU Period

Voucher
No.

UC SUBMITTED BY NGO/PP

Quarter 2 (to )

Advance/Reimbursement

Date UC
Received

Amount
Rs.

If
advance,
whether
entered
in
Advance
Register
(Yes/No)

RELEASES TO NGO/PP

Release for 1st Half-year of MoU Period

Amount

Cheque
number

Rs.

Date

Voucher
No.
Advance/
Reimbursement

Release for 1st Half-year of MoU Period

Rs.

Grantin-Aid
as per
MOU

Releases to NGO/PP

MOU dated

Period of Scheme

Name of Scheme

Name of NGO/PP

(Yes/No)

If advance,
whether
entered in
Advance
Register
Date

Voucher
No.

Cheque
number

Rs.

Amount

Advance/
Reimbursement

Release for 2nd Half-year of MoU Period

Annexure 1c Format for NGO/PP Payment and UC Monitoring Register

Annexure - 1C
Format for NGO/PP Payment and UC Monitoring Register

(Yes/No)

If advance,
whether
entered in
Advance
Register

d= b +c

Rs.

Total
Released

Training Course for Program Manager

TU SCHEME
UC SUBMITTED BY NGO/PP
Quarter 1 (to )

Quarter 2 (to )

Quarter 3 (to )

Quarter 4 (to )

Date UC
Received

Date UC
Received

Date UC
Received

Date UC
Received

Cumulative
Exp. as
per UC
Rs.

Cumulative
Exp. as per
UC
Rs.

Cumulative
Exp. as per
UC
Rs.

148

Cumulative
Exp. as per
UC

Unspent
Balance

Rs.

Rs.

f= a - e

Training Course for Program Manager

ANNEXURE II- FINANCIAL MANAGEMENT


Second National Tuberculosis Control Project (TB-II)
Procurement Procedures for States/Districts
A. Background:
The Ministry of Health & Family Welfare (MoHFW), Government of India, is availing
financial assistance from the World Bank for TB-II project. Hence, the procurement
funded by these agencies will not be governed by the state government procedure, but
by the agreed procurement procedure applicable for TB-II, which is described below:

B. General:
1) The states will circulate this note on TB-II procurement procedure to all concerned
officials in the health directorate, state and district societies and any other agency
involved in procurement using TB-II fund.
2) The books/records/contracts etc. pertaining to TB-II funding will be kept separately.
As per the agreement with the Government of India, the World Bank will conduct a
procurement audit of a sample of the procurement undertaken under the RCH II
Program every quarter. Records should therefore be maintained in a systematic
fashion so it is easy to select a representative sample of procurement transactions
to be reviewed from the records. Likewise the MoHFW will also conduct annual
procurement audits.
3) The TB-II procurement guidelines are applicable to procurement of goods, works as
well as services (such as training/workshops), IEC activities (printing or distributing
material through an agency), research and studies, hiring of consultants, NGO
services, PPP agreements and other similar contracting).
4) The states will compile the list of contracts issued from TB-II funding at state and
district level and forward this list to the Central TB Division (CTD), MoHFW within 15
days of closing of every quarter in the following format:
Contract/ P.O. Method of
Procurement
Description

Category
(Goods/
Value (Rs.)
Works/Services)

Issued to
(name of
contractor/
supplier)

Date of
Issue (of
new
Contract)

5) As per the agreed procurement procedure, the state and district will not procure
drugs, pharmaceuticals and medical supplies from TB-II funding. However, these
could be procured from the other sources such as NRHM or state government.
6) As per the agreed procurement procedure, the state and district will not procure any
goods, works or service contract exceeding US$ 50,000/- equivalent or less per
contract from TB-II funding (now revised to US$ 30,000/- equivalent or less per
149

Training Course for Program Manager


contract at state level and US$ 10,000/- equivalent or less per contract at district
level for procurement of goods and works).
7) As per the TB-II procurement guidelines, financial negotiations are not permissible.
Under exceptional circumstances, negotiations can be carried out only with the
lowest bidder.
8) The states would depute the officials dealing with TB-II procurement for the training
program proposed to be organized by CTD, MoHFW.
9) Procurement under TB-II will be handled directly by state government or societies.
Outside agencies (procurement support agencies) will not be used by the states or
districts for handling procurement under TB-II.
10) The procurement decisions shall be approved by the Procurement Committees as
per the delegations suggested by CTD.
11) Contract award information should be put on the website of the state societies
wherever possible.
12) Complaints related to procurement should be addressed satisfactorily.

C. TB-II Procurement Procedure for Goods and Works


1) Shopping/Limited Tendering (subject to the revised maximum cost US$
30,000/- equivalent or less per contract at state level and US$ 10,000/equivalent or less per contract at District level)
(a) Shopping is a procurement method based on comparing price quotations
obtained from several suppliers, usually at least three to ensure competitive
prices.
(b) Pharmaceuticals, medical supplies and other goods (excluding drugs) and works
estimated to cost $ 30,000/- equivalent or less per contract at state level and $
10,000/- equivalent or less per contract at District level (revised cost), may be
procured under contracts awarded on the basis of Shopping.
(c) It is an appropriate method for procuring readily available off-the-shelf goods or
standard specifications commodities of small value or simple civil works of small
value.
(d) Approval of competent authority may be obtained for items to be purchased or
civil works to be constructed/ renovated/ repaired along with specifications,
estimated costs and agencies from whom quotations should be invited.
(e) The requests for quotations shall be made indicating the description,
specification, and quantity of the goods, terms of delivery or specifications of
works, as well as desired delivery or completion of time and place. If the
quotations are called for more than one item/works, it should also be indicated
150

Training Course for Program Manager


whether the evaluation would be for each item-wise or for civil works or as a
package.
(f) Quotations could also be obtained by telex or facsimile. The terms of the
accepted offer shall be incorporated in a purchase order or brief contract.
(g) Rate contracts entered by the state governments cannot be used under
shopping.
(h) Rate Contract entered into by Directorate General of Supplies and Disposal
(DGS&D) will be acceptable for procurement under shopping.
2) Single Tender /Direct Contracting (subject to a maximum value of US$ 10,000/or equivalent per Contract)
(a) The Single Tender system may be adopted in case of articles which are
specifically certified as of proprietary in nature, or where only a particular firm is
the manufacturer of the articles demanded or in case of extreme emergency.
(b) The single tender system without competition shall be an appropriate method
under the following circumstances: (i) Extension of existing contracts for works or
goods awarded with the prescribed procedures, justifiable on economic grounds;
(ii) Standardization of equipment or spare parts to be compatible with existing
equipment may justify additional purchases from the original supplier; (iii) The
required item is proprietary and obtainable only from one source; (iv) Need for
early delivery to avoid costly delays; (v) Works are small and scattered or in
remote locations where mobilization costs for contractors would be unreasonably
high; and (vi) In exceptional cases, such as in response to natural disasters.
(c) Rate contracts entered by the state governments can be used under single
tender/direct contracting.

D. Hiring of Consultants and Service Providers


1) Single source selection of Firms (subject to a maximum value of US$ 50,000/or equivalent per contract)
Single source selection may be appropriate only if it presents a clear advantage
over competition and on account of the following reasons:

For tasks that represent a natural continuation of previous work carried out by the
firm.
Where a rapid selection is essential (emergency operation).
For small assignments; or
When only one firm is qualified or has experience of exceptional worth for the
assignment.

151

Training Course for Program Manager


2) Individual Consultants (subject to a maximum value of US$ 50,000/- or
equivalent per Contract):
For hiring of individuals, it is necessary to finalize the job description, qualification
and experience required and terms of engagement. Thereafter an advertisement (if
the assignment is complex) may be put into the national/ regional newspapers
indicating the above details. The applications received shall be scrutinized and
ranking shall be prepared. Thereafter the top-ranked individual shall be invited for
interviews/discussions and would be offered the assignment. In exceptional cases,
the individual consultant may also be selected based on single source.
3) Quality and Cost Based Selection (subject to a maximum value of US$ 50,000/or equivalent per Contract):
The procedures to be followed in all cases of selection of consultant, and is given
below in brief.
Steps

Establish the need for the assignment and outsourcing the services
Preparation of the Terms of Reference (TOR)/Scope of Work/Job Description
Preparation of cost estimate and the budget
Preparation of the shortlist of consultants
Preparation and issue of Request for Proposal (RFP)
o Letter of Invitation (LOI)
o Information to Consultants (ITC)
o Proposed contract
Receipt of proposals
Opening and Evaluation of technical proposals
Evaluation of financial proposal
Combined evaluation of quality and cost
Award of the contract to the selected firm

4) Least Cost Selection (subject to a maximum value of US$ 50,000/- or


equivalent per Contract):
Under this method, a minimum qualifying mark for the quality is established and
shared in the Request for Proposal (RFP). Proposals, to be submitted in two
envelops, are invited from a short list. Technical proposals are opened first and
evaluated. Those securing less than the minimum qualifying mark are rejected, and
the financial proposals of the rest are opened in public. The firm with the lowest price
shall then be selected.
Steps

Establish the need for the assignment and outsourcing the services
Preparation of the Terms of Reference (TOR)/Scope of Work/Job Description
Preparation of cost estimate and the budget
Preparation of the shortlist of consultants
152

Training Course for Program Manager

Preparation and issue of Request for Proposal (RFP)


o Letter of Invitation (LOI)
o Information to Consultants (ITC)
o Proposed contract
Receipt of proposals
Opening and Evaluation of technical proposals
Opening of financial proposal of the firms securing more than qualifying marks
Award of the contract to the firm quoting the lowest price

153

Table of Contents
Module 7
Programme Logistics Management Including Preventive Maintenance
Learning Objectives ...............................................................................................................
Drugs for TB Treatment ........................................................................................................
Effective Drug supply and Management system ...................................................................
Guideline for proper storage of Anti TB drugs .....................................................................
Stock Register Format ...........................................................................................................
Exercise on district level worksheet for reporting drug requirement ..................................
Annexure I to X .....................................................................................................................

157
157
158
160
163
171
188-197

Training Course for Program Manager

Module 7
Logistics Management Including Preventive Maintenance
Learning objectives
In this module participants will learn the roles and responsibilities of program manager at
each level in logistics and maintenance as mentioned below:
(I)
(II)

(III)

Logistics of Anti-TB drugs


Logistics of other items
a) Treatment-related supplies such as syringes, needles, water for injections,
water containers, disposable tumblers etc.
b) Lab consumables (reagents, sputum containers, slides, universal containers
for C&DST etc)
c) Forms, registers and reports
d) Binocular Microscopes (BM)
e) Four-wheelers, two wheelers, photocopier, computer, etc
Preventive maintenance of equipments, vehicles etc.

Introduction
Prompt procurement and maintenance of uninterrupted logistics is one of the important
prerequisite for the successful implementation of the Programme. Procurement, storage,
maintenance of reserve stock and distribution of anti-TB drugs and other materials are
essential for quality services under Revised National TB Control Programme. One of the
most important tasks is to make sure that all health facilities have the drugs and materials.
(I)

LOGISTICS OF ANTI-TB DRUGS


ROLE OF STATE/DISTRICT TB OFFICERS /MO-TCs IN DRUG LOGISTICS
SYSTEMS (DLS)
The STOs/DTOs/MO-TCs have a vital role in implementing RNTCP drug logistics
guidelines and ensuring effective drug management systems in the
state/districts/TUs.
The key responsibilities of the STO/DTO/MO-TC include the following:
Overall supervision of State/District/TU Drug Stores operations and inventory
management of drugs including physical verification.
Review of drug stock adequacy at all levels, ensuring their uninterrupted supply
thereby preventing stock-outs
Timely submission of the quarterly report of state/district/TU and monthly report
to the SDS
Timely corrective action to prevent drug expiry
Timely action to redistribute drugs to prevent local shortages
Training of State/District/sub-district level officials dealing in drug management

Drugs for TB treatment


An uninterrupted supply of quality TB drugs is one of the five components of DOTS
strategy. A strong procurement and logistics management with respect to drugs is essential
to strengthen every link in the drug supply chain, from manufacturer to patient. India has
157

Training Course for Program Manager


developed a unique system of providing drugs in Patient Wise Boxes (PWBs) which contain
drugs for the entire duration of treatment for patient. Once a patient is started on anti-TB
treatment, a box is assigned to the patient, thus ensuring that the entire course is available
uninterrupted. All efforts in this direction were made possible by analyzing and improving
existing systems. As a result of this, significant improvements in manufacturing, inspection,
supply, storage and quality control practices and procedures have been achieved.
An efficient drug logistics system should ensure:
Continuous availability of quality anti-TB drugs
Maintenance of adequate drug stocks at all levels
Prevention of expiry of drugs at all levels
Effective timely transportation of drugs
Proper maintenance of drug record
Quality of drugs throughout its shelf life
Safeguarding against pilferage

Effective Drug Supply and Management System


An effective drug supply and management system encompasses the activities of
Selection
Procurement
Distribution
Usage
Reporting and Monitoring
Quality Assurance of Drugs
1. Selection
The essential first line drugs used in the Revised National TB Control Programme
are: Rifampicin, Isoniazid, Ethambutol, Pyrazinamide and Streptomycin.
2. Procurement of Anti TB Drugs
Under RNTCP Phase II, Procurement, Supply & Logistics Unit has been established
in Central TB Division (CTD) for procurement and logistics. The unit is under the
supervision of a Chief Medical Officer and is supported by a Procurement & Supply
Management Consultant. The procurement is done through a Procurement Agency
hired by MOHFW, based on requirement calculations and technical specifications
formulated by CTD, pursuant to their approval by a Technical Committee. An
agency, outsourced with the support of WHO is performing Drug Logistics functions
at the CTD.
Procurement of Drugs for 500 million population of the country is presently being
done by the Global Drug Facility (GDF) through financial support by DFID. For the
rest of the population, the procurement (both for World Bank and GFATM funded
states) is done at the level of Ministry of Health & Family Welfare (MOHFW), Govt. of
India from Pre-Qualified Suppliers defined as manufacturers complying WHO-Good
Manufacturing Practices (GMP) as assessed by WHO Pre-qualification Programme.
The procurement of Second Line Anti TB Drugs for the World Bank funded states is
done through International Competitive Bidding (ICB) by the procurement agency of
158

Training Course for Program Manager


MOHFW. For the states funded by GFATM, these drugs are procured through Green
Light Committee (GLC) of Stop TB Partnership.
3. Distribution
a. First line drugs
Distribution of drugs is to be carefully monitored, so as to ensure uninterrupted
availability of quality drugs. Requirements at drug stocking points are based on
current utilization patterns and expected stocks at the time of delivery.
Distribution of first line drug supplies is primarily effected from the manufacturer to
Government Medical Stores Depots (GMSDs) at Karnal, Mumbai, Kolkata, Chennai,
Guwahati and Hyderabad.
Central TB Division issues drugs based upon closing stocks and stocking norms.
The drugs are issued from the GMSDs either to the districts (in absence of an SDS)
or to the SDS for onward distribution to the districts. GMSDs take about 15 days to
dispatch the drugs up to districts or SDS (around 7-10 days). The SDS/ Districts
should follow up with the GMSDs in case of delay in receipt of drugs after receipt of
Release Order from Central TB Division. Drugs once received by the SDS are then
transported to the districts. The districts then pass the drugs to the TUs which in turn
supply them to the PHIs. It takes about 2 months after the beginning of a new
quarter for the fresh stocks of drugs to reach the SDS/ Districts.

CTD
Consignee list
Procurement Agency
Release orders

Supply Order
Manufacturer

SDS

GMSDs
Exceptions
Districts

Distribution Cycle
159

Training Course for Program Manager


b. Second line drugs
Distribution of second line drug supplies is effected from the manufacturer to the
State Drug Stores directly.
State Drug Store (SDS)
Over the past few years, the responsibility of drug logistics management has been
commendably taken up by the States which can be seen in the fact that more than 40 State
Drug Stores (SDS) have been established in various States in the country. SDSs are
essential for decentralizing drug management at State level and in sharply reducing leadtimes for fulfilling drug requests (norm 1 SDS for 50 million population). SDS reduces the
complexity of logistics management for CTD and GMSDs. SOPs have been developed by
CTD for SDS and DDS (District Drug Store). A few of the operational formats such as Stock
Registers, Worksheet for Reporting Drug Requirement (WRDR) etc. are given as
Annexures (III to V).
Stacking of Anti-TB Drugs
The State/DTO must ensure that the Storekeeper performs the following activities with
respect to the storage/ stacking of Anti-TB Drugs:
(1) Ensure that different drug items are clearly segregated and stacked on separate
racks
(2) Different batches of drugs with different dates of manufacture and expiry are stored
separately so as to facilitate FEFO principles viz. drug batches with the most recent
expiry are issued first.
(3) Mark Expiry Dates in bold letters 3 to 4 in size, on the drug cartons with a Marker
Pen, for easy identification and control of drugs immediately on their arrival.

GUIDELINES FOR PROPER STORAGE OF ANTI-TB DRUGS


Importance of good storage conditions and safe custody of drugs in addition to good
logistics management is also stressed upon the States. The STO/ DTO must ensure that
the store-keeper adheres to the following guidelines on proper storage of drugs.
1.
2.
3.
4.
5.
6.
7.
8.
9.

Clean and disinfect storeroom regularly.


Store supplies in a dry, well-lit, and well-ventilated storeroom, out of direct sunlight.
Secure the storeroom from water penetration.
Ensure that fire safety equipment is available and accessible, and that personnel are
trained to use it.
Stack cartons off the floor, away from the walls and not all one over the other
Store medical supplies separately, away from insecticides, chemicals, old files, office
supplies, and other materials.
The identification label, expiry date & manufacturing date of the Category PWB/
Pouches /Loose drugs etc should be marked with a bold marker pen on the visible
side of the carton
Store supplies in a manner accessible for First-Expiry-First-Out (FEFO), counting,
and general management.
Separate and dispose off damaged or expired products without delay as soon as
approval of the same has been received.

160

Training Course for Program Manager


Stock Register
A Stock Register is maintained at the SDS, districts & TU level drug stores in the prescribed
format as given overleaf. A Stock Register is maintained to record receipt, issue and
balance stock of drugs. The status of stock along with their expiry details can be
ascertained at any point of time through this register.
Example: There are four batches of Product Code -1 (Cat-I) drug boxes in the DTC with
expiry dates as Jan-10, May-10, Sept-10 and Dec-10. Column i should contain balance
quantity of drugs for new cases with expiry date as Jan-10, Column m with expiry date as
May-10, Column n with expiry date as Sept-10 and Column o with expiry date as Dec-10.
As and when, the entire quantity of the drug with a particular expiry date stands completely
issued, the balance in that particular column (l to o) shall become Nil or Zero on the date
on which the last issue is made. As and when, the drugs with a new Expiry Date are
received; the new Expiry Date is mentioned at the top of the column.
Before making any issue of drugs, the storekeeper should always look at columns (l) to (o)
and check as to which drugs are due to expire first. The drugs, which are due to expire first,
are to be issued first so that all the drugs issued will follow the FEFO principles
Carry Forward of Balances: While carrying forward the balances with different expiry
dates from a filled-up page on to a new page of the Stock Register, it should be ensured
that the columns (l) to (o) should record the Expiry Dates in an ascending order, i.e. the
balance of drugs with an earliest expiry date should be recorded in column (l), whereas
balance of drugs with a later expiry date should be recorded in column (m) and so on.
As seen in the above example, the Stock Register facilitates issue of drugs as per FEFO
principles. However, while the Storekeeper shall strictly follow FEFO principles, it is
also expected of him to ensure that all short-expiry drugs do not get issued to one
district/sub-district. Instead, distribution shall be based on the utilization pattern of
each district/sub-district.
An Exercise on Stock Register along with the format is available overleaf. Solution to the
Exercise is available at Annexure-III.
Exercise on Stock Register
The following transactions occurred during the month of Nov 2008.
Opening Balance of PC-1 as on 1.11.2008: 10 PWBs (from the batch no XY received from
RBL; Date of Expiry Aug-10)
Receipts of Drug: PC-1 (Cat-I)
Batch
No.

Date of
Receipt

Date of
Mfg.

Date of
Expiry

Qty.
Received
(Nos.)

AB

10.11.2008

Nov-07

Oct-10

60

CD

15.11.2008

Dec-07

Nov-10

50

EF

25.11.2008

Jan-08

Dec-11

10

161

Name of
Party
(Supplier)
GMSD
Karnal
GMSD
Mumbai
SDS Delhi

Invoice No./
Receipt
Voucher No.

Date of
Invoice/
Voucher
No.

IV 35

1.11.2008

IV 14

8.11.2008

DTA 68

12.11.2008

Training Course for Program Manager


Issues of Drug: PC-1 (Cat-I)
Date of Issue
17.11.2008
26.11.2008
29.11.2008

Quantity Issued
(Nos.)
30
40
40

Sent/Issued to

Issue Voucher No.

DTC - A
DTC - B
DTC - C

SIV No. 1
SIV No. 2
SIV No. 3

Date of Issue
Voucher
17.11.2008
26.11.2008
29.11.2008

Please record the above transactions in the Stock Register format provided on the page overleaf.

162

10

(c)

Name of
Party
(GMSD/
SDS/
DTC/TU)

GMSD
Karnal

Folio No.:

IV-35

(d)
-

(e)

1.11.2008

(f)

(h)

AB

Oct-10

XY Aug-10

(g)

60

(i)

(j)

70

10

(k)

10

10

(l)

60

(m)

(n)

(o)

(p)

(q)

RECEIPT ISSUE BALANCE DATE-WISE EXPIRY DETAILS SIGNATURE REMARKS


(Qty.) (Qty.)
(Qty.)
OF BALANCE (Qty.)
OF STOREKEEPER
Receipt Issue
Date of Batch Date
Expiry Expiry Expiry Expiry
Voucher Voucher Issue/
No.
of
Date Date
Date
Date
No. (For No.(For Receipt
Expiry
(Aug- (Oct- () ()
Receipts Issues Voucher
10)
10)
only)
only)

Unit of Measurement (UOM): Boxes

PARTICULARS OF RECEIPTS & ISSUES

1.11.2008 Op Balance

(b)

Date (Dd/
mm/ yy) of
Transaction
(Receipt/
Issue)

2 10.11.2008

(a)

SL.
NO.

Drug Item: PC-1 (Cat-I)

STOCK REGISTER (SR)

Training Course for Program Manager


Physical Verification of drug stocks in the stores: Ensure that the quantity of drugs in
the Stock Register matches with the physical stock balance in the drug store. For this
purpose, physical verification should be carried out every quarter & reported to the State
/CTD in the prescribed format. Any shortage or excesses should be substantiated by
submission of a report.
4. Usage
Adult PWBs should be provided to the patients through the DOT Providers only from the
PHIs. However, Pediatric PWBs should be provided through the DOT Providers from the
TU drug store. Besides timely availability of drugs to the patients after diagnosis, thorough
dispensing instructions should also be provided to the patient.
Pediatric Patient-Wise Boxes:
Schedule of Requirement for RNTCP
Sl.No Product Code Number

Product Description

Strength

Each combi-pack of
Schedule-5 containing
1 R Tab .of 75mg
1
Product Code 13
1 H Tab. of 75mg
1 E Tab of 200mg
1 Z Tab. of 250mg
Treatment box for pediatric category (11-17 Each combi-pack of
Kg, 18-25 & 26-30 Kgs). Each treatment box Schedule 7 Containing
containing 24 combi-packs of Schedule-7 in 1 R Tab.of 150mg
2
Product Code-14
1 H Tab. of 150mg
one pouch and 18 multi-blister calendar
combi-pack of Schedule-8 in another pouch 1 E Tab of 400mg
1 Z Tab. of 500mg
Treatment box for prolongation of intensive
Each combi-pack of
Schedule - 5 Containig
Product Code-15
phase of pediatric cases (6-10 &18-25 kg).
Each box containing 5 pouches and each
1 R Tab.of 75mg
3
pouch containing 12 blister combipack of
1 H Tab. of 75mg
Schedule-5
1 E Tab of 200mg
1 Z Tab. of 250mg
Treatment box for prolongation of intensive
Each combi-pack of
Schedule 7 Containing
Product Code-16
phase of pediatric cases (11-17, 18-25 kg
and 26-30 kg). Each box containing 5
1 R Tab.of 150mg
4
pouches and each pouch containing 12
1 H Tab. of 150mg
blister combipack of Schedule-7
1 E Tab of 400mg
1 Z Tab. of 500mg
R= Rifampicin; H= Isoniazid; E= Ethambutol; Z= Pyrazianamide; S.M= Streptomycin Inj; X= Pyridoxine
Treatment box for pediatric category (6-10
Kg, & 18-25 Kgs). Each treatment box
containing 24 combi-packs of Schedule-5 in
one pouch and 18 multi-blister calendar
combi-pack of Schedule-6 in another pouch

Unit
Each multi-blister calender combi-pack
of Schedule-6 containing
3 R Tabs.of 75 mg each
3 H Tabs. of 75mg each
4 Pyridoxine Tabs of 5mg each
Each multi-blister calender combi-pack
of Schedule-8 containing
3 R Tabs.of 150 mg each
3 H Tabs. of 150mg each
4 Pyridoxine Tabs of 5mg each

Treatment
Boxes

Treatment
Boxes

Treatment
Boxes

Treatment
Boxes

Drug Management for Pediatric drugs is similar to that of adult PWBs except that Pediatric
boxes are to be stocked only upto the TU level, as currently these boxes are available for
only New cases & any modification to convert these boxes to previously treated regimen
can be done only at the TU level. Conversion of PWBs for new cases to PWBs for
previously treated cases can be shown as below:
Conversion of Pediatric Box for new cases into Pediatric Box for previously treated
cases One Prolongation Pouch would be added to each box to make an IP pouch of 3
months duration.
For prolongation of IP for previously treated cases, one more PP would be added
As the CP pouch of PWBs of new cases would contain drugs for 4 months, a PP
would be added for extra 1 month of CP after removing Pyrazinamide tablets,.
As the 4 months of CP blisters for new cases contain only Cap. Rifampicin and Tab.
INH, so Ethambutol tablets will have to be added from the supplies of loose drugs
under the Programme.
Inj.SM (750 mg) supplied under the programme shall be used for such patients as
per body weight.
164

Training Course for Program Manager


A chart depicting the preparation and use of Pediatric PWBs for the corresponding body
weights is placed below as a desk reference chart:DESK REFERENCE FOR PREPARATION & USE OF PEDIATRIC DRUGS
Body
Weights

New Cases

Prolongation for
New Cases

Previously treated cases

6-10 Kg

One PC 13
Box

One Pouch of PC
15

11-17 Kg

One PC 14
Box

One Pouch of PC
16

18-25 Kg

One PC 13
Box + One
PC 14 Box

One Pouch of PC
15 + One Pouch
of PC 16

26-30 Kg

Tow PC 14
Boxes

Two Pouches of
PC 16

Add one pouch of PC 15 to IP.


Add one pouch of PC 15 to CP after removing
Tab pyrazinamide (250 mg.)
Add 54 Tab Ethambutol (800 mg) to the
existing 4 months CP of PC -15 (200 mg to be
administered and the rest discarded)
Also, 24 vials of Inj S M to be used in IP (to be
administered @ 15 mg / kg)
Add one pouch of PC 16 to IP.
Add one pouch of PC 16 to CP after removing
Tab pyrazinamide (500 mg.)
Add 54 Tab Ethambutol (800 mg) to the
existing 4 months CP of PC -16 (400 mg to be
administered and the rest discarded)
Also, 24 vials of Inj S M to be used in IP (to be
administered @ 15 mg / kg)
Add one pouch of PC 15 and one pouch of PC
16 to IP.
Add one pouch of PC 15 and one pouch of PC
16 to CP after removing Tab pyrazinamide (250
mg. and 500 mg respectively)
Add 54 Tab Ethambutol (800 mg) to the
existing 4 months CP (600 mg to be
administered and the rest discarded)
Also, 24 vials of Inj S M to be used in IP (to be
administered @ 15 mg / kg)
Add one pouches of PC 16 to IP.
Add one pouch of PC 16 to CP after removing
Tab pyrazinamide (500 mg.) from both the
boxes.
Add 54 Tab Ethambutol (800 mg) to the
existing 4 months CP
Also, 24 vials of Inj S M to be used in IP (to be
administered @ 15 mg / kg)

Prolongation
for
Previously
treated cases

One Pouch of
PC 15

One Pouch of
PC 16

One Pouch of
PC 15 + One
Pouch of PC
16

Two Pouches
of PC 16

Chemoprophylaxis : Loose tablets of INH 100 mg are supplied by CTD based on the
district Quarterly Report on Programme Management & Logistics (QRPML)
Requirement of Prolongation Pouches for indoor patients:
The officer-in-charge of the hospitals can obtain these prolongation pouches from their
concerned TUs based on consumption reported in their monthly PHI report.
Requirements of Non-DOTS loose drugs:
In exceptional cases, non-DOTS regimens may have to be used under RNTCP. These
drugs can be obtained, based on actual requirements.
165

Training Course for Program Manager


4. Reporting and Monitoring
(a) Reporting:The regular process of supply of new stock of drugs to the districts / SDS begins only
when the districts submit their QPMR. The reports of the stocking units are to be
submitted as per the schedule mentioned below:
Report of Stocking
unit
PHI to TU
TU to DTC
DTC to SDS / STO/
CTD
SDS to CTD

Date of submission of report


1st week of each subsequent month
7th of the subsequent month after the quarter
10th - 24th of subsequent month after the quarter
24th of the subsequent month after the quarter

All PHIs submit Monthly Report on Program Management and Logistics (MRPML) to
the TUs. The TUs in turn consolidate these reports into QRPML-TU and submit to
the district level.
The district quarterly reports are validated by the State TB Cell based on which
drugs are issued by the SDS before end of the first month after the quarter.
Respective states are also expected to make arrangements for transportation of
drugs from SDS to District Tuberculosis Centres (DTCs). The DTC is responsible for
transporation of drugs to TU and onwards. The district QRPML is submitted to CTD
latest by 24th of the subsequent month after the quarter with a copy to the STO.
It is very important to make sure that every health facility in the district gets
adequate supply of anti-tuberculosis drugs. Timely initiation of treatment is not
possible if the supply of drugs is inadequate. The basis for stocking adequate
amount of drugs at various levels is described in the following paragraphs.
The MRPML from PHI & QRPML from TU, District and State level contain the
following tables for drug position:
PHI Monthly Report on Programme Management & Logistics:
Adult Patient Wise Boxes
Item

(a)

Unit of
Measurement
(b)

PC-1

Patient Wise
Boxes PWBs)

PC-2

PWBs

Stock on
first day of
month
(c)

Stock
received
during
month
(d)

166

Patients
initiated on
treatment

Stock on
last day of
month

Quantity
Requested

(e)

(f)= (a+b)-c

(g)= (c X 2) - d

Training Course for Program Manager


Prolongation Pouches and Inj SM
Item

Unit of
Measurement

Stock on
first day
of month

Stock
received
during month

Consumption
during the
month

Stock on last
day of month

Quantity
Requested

(c)

(d)

(e)

(f)=(c+d)-e

(g)=e 2)-f

Stock on
first day
of month

Stock received
during month

Consumption
during the
month

Stock on
last day of
month

Quantity
Requested

(c)

(d)

(e)

(f)=(c+d)-e

(g)=e 2)-f

(a)

(b)

Prolongation
Pouches

Pouches each
with 12 blister
strips

Streptomycin
0.75 g

Vials

RNTCP Loose Drugs


Item

Unit of
Measurement

(a)
INH 300 mg
INH 100 mg
Rifampicin
150 mg
Ethambutol
800 mg

(b)
Tablets
Tablets
Capsules
Tablets

For MRPML of PHI-level, all information is available from the stock register of the PHI
stores. The stock on first day of the month should always be equal to stock on last day of
the previous month. The information on stock received during the month would comprise
of receipts from its TU as recorded in the stock register. Similarly, information on Patients
initiated on treatment would comprise of all the issues i.e. No. of patients put on treatment.
The Closing Stock is then calculated as opening stock + Receipts patients initiated on
treatment. However, this figure will be equal to what is available in the PHI stores also.
Hence, a monthly physical verification should be considered essential to ensure that there
is no difference between the two. To calculate Quantity Requested, the following formula
is used [(No. of patients initiated on treatment x 2)- closing stock]. This will ensure that
the PHI receives its supply from its TU as per stocking norms discussed above.
Similarly, the information about laboratory consumables available in the stock register
maintained in the laboratory is to be filled.
TU Level : Medications
Adult Patient Wise Boxes
Item

Unit of
Measurement

(a)

(b)

PC-1

Patient
Wise
Boxes (PWBs)

PC-2

PWBs

Stock on Stock received


during the
first day of
quarter
Quarter
(c)

(d)

167

Patients
initiated on
treatment

Stock on last
day of Quarter

Quantity
Requested

(e)

(f)=(c+d)-e

(g)=(e/3 4)-f

Training Course for Program Manager


Prolongation Pouches, Inj. SM and Tab. Co-trimoxazole
Unit of
Measurement

Items
(a)
Prolongation
Pouches

(b)
Pouches each
with 12 blister
strips

Streptomycin
0.75 g

Vials

Co-trimoxazole

Monthly pouch
(of 30 tabs.)

Stock on
first day
of quarter
(c)

Stock
received
during the
quarter
(d)

Consumption
during the
quarter

Stock on
last day of
Quarter

Quantity
Requested

(e)

(f)=(c+d)-e

(g)=(e/3 4)-f

Paediatric Patient Wise Boxes (Including drugs for Adult Patients <30kgs)
Items

Unit of
Stock on
Stock
Consumption Stock on last
during the day of Quarter
Measurement first day of received
quarter
quarter
during the
quarter
(a)

(b)

Paediatric PC 13

Boxes

Paediatric PC 14

Boxes

Paediatric PC 15

Paediatric PC 16

(c)

(d)

(e)

(f)=(c+d)-e

Quantity
Requested

(g)=(e/3 4)-f

Pouches each
with 12 blister
strips
Pouches each
with 12 blister
strips

RNTCP Loose Drugs


Items

(a)

Unit of
Measure
ment

Stock on
first day of
quarter

Stock
received
during the
quarter

(b)

(c)

(d)

INH 300 mg

Tablets

INH 100 mg

Tablets

Rifampicin
150 mg

Capsules

Pyrazinamide
750 mg

Tablets

Ethambutol
800 mg

Tablets

168

Consumption Stock on last


during the
day of quarter
quarter
(e)

(f)=(c+d)-e

Quantity
Requested

(g)=(e/3 4)-f

Training Course for Program Manager


Drugs for MDR TB
PWBs for

Unit of
measure
ment

(a)

(b)

IP (16-25 Kg Body Weight)

Box

IP (26-45 Kg Body Weight)

Box

IP (>45 Kg Body Weight)

Box

CP (16-25 Kg Body Weight)

Box

CP (26-45 Kg Body Weight)

Box

CP (>45 Kg Body Weight)


Na PAS for one month in 3
boxes (100 gms each)

Stock
on first
day of
quarter
(c)

Stock
received
during
the
quarter
(d)

Consumption
during the
quarter
(e)

Stock on
last day of
quarter

Quantity
Requested

(f)=(c+d)-e

(g)=(e 2)-f

Box
Carton of 3
boxes

1. Is there any drug at the risk of expiry*?

Yes / No If yes attach details

* PWB for New Cases within 12 months; PWB for previously treated cases within 14 months;
PC 13 & PC 14 - within12 months; PWB for MDR TB Treatment Regimen within 6 months
2. Are there any expired drugs?

Yes / No If yes attach details

For preparation of QRPML of TU-level, three PHI monthly reports are to be


consolidated in the Worksheet for Reporting Drug Requirement (WRDR) -TU format, as
given in Annexure IV. The WRDR-TU facilitates correct consolidation of the reports
and thus helps in preparation of the TU-QRPML .
WRDR-TU: The data of all the PHI reports shall be put in the WRDR-TU format along with
the information of the stock register at the TU drug stores. The total of all the PHI Reports &
the TU drug store shall comprise the TU-QRPML. Prior monthly physical verification of the
TU-store is essential for ensuring accurate reporting. However, to calculate Quantity
Requested, No. of patients initiated on treatment/3 x 4 minus total closing stock at PHIs &
TU shall ensure that the TU receives its supply from its DTC as per stocking norms
discussed above.

DTC Level: Medication


Adult Patient Wise Box
Item

(a)

Unit of
Measurement

Stock
on first
day of
Quarter

Stock
received
during
the
quarter

Stock
transfe
rred in

Reconstitution
of boxes
during Quarter

Stock
Transferred
Out *

Patients
started on
treatment

Stock on last
day of
Quarter

Quantity
Requested

(b)

(c)

(d)

(e)

(f)

(g)

(h)

(i)=(c+d+e+f)
(g+h)

(j)=(h/3 7)
-i

PC-1

PWBs

PC-2

PWBs

169

Training Course for Program Manager


Prolongation Pouches and Inj SM
Unit of
Measurement

Stock
on first
day of
Quarter

Stock
received
during
the
quarter

Stock
transferr
ed in

Reconstit
ution
during
Quarter

Stock
Transferr
ed Out *

Consumption
during the
Quarter

(a)

(b)

(c)

(d)

(e)

(f)

(g)

(h)

Prolongation
Pouches

Pouches
each with
12 blister
strips

Streptomycin
0.75 g

Vials

Item

Stock on last
day of Quarter

Quantity
Requested

(i) =
(c+d+e+f)
(g+h)

(j) =
(h/3 7) - i

Paediatric Patient Wise Boxes (Including PWBs for Adult Patients <30kgs)
PWBs

(a)
Paediatric PC 13
Paediatric PC 14
Paediatric PC 15
Paediatric PC 16

Unit of
Stock on
Stock
Stock Reconstitution Stock Consumption Stock on last day Quantity
Measurement first day received transferred of boxes Transferred during the
Requested
of Quarter
during the
of
during
quarter
in
Out *
quarter
Quarter
Quarter
(b)
(c)
(d)
(e)
(f)
(g)
(h)
(i)=(c+d+e+f) (j)=(h/3 7)
(g+h)
i
Boxes
Boxes
Pouches
each with 12
blister strips
Pouches
each with 12
blister strips

RNTCP Loose drugs


Item

(a)

Unit of
Measurement

Stock on
first day
of
Quarter

Stock
received
during the
quarter

Stock
transferred
in

Stock
Transferred
Out *

Consumption
during the
quarter

Stock on last
day of
Quarter

Quantity
Requested

(b)

(c)

(d)

(e)

(f)

(g)

(h)=(c+d+e)

(i) =
(g/3 7) h

(f+g)
INH 300 mg

Tablets

INH 100 mg

Tablets

Rifampicin
150mg

Capsules

Pyrazinamide
750 mg

Tablets

Ethambutol
800 mg

Tablets

Drugs for MDR TB


Item

Unit of
measurement

Stock on
first day of
the Qtr

Stock
received
during the
Qtr

Consumption
during the
Qtr

Stock on last
day of the
Qtr

Quantity
Requested
for DTC

(a)

(b)

(c)

(d)

(e)

(f)=(c+d)-e

(g)=(e 2)-1

IP ( 45 Kg Body wt )

Box

IP ( > 45 Kg Body wt)

Box

170

Training Course for Program Manager


CP ( 45 Kg Body wt)

Box

CP ( > 45 Kg Body wt)

Box

Na PAS for one


month in 3 boxes (100
gms each)

Carton of 3
boxes

1. Is there any drug at the risk of expiry*?

Yes / No If yes attach details

* PWB for New Cases within 12 months; PWB for previously treated cases within 14 months;
PC 13 & PC 14 - within12 months; PWB for MDR TB Treatment Regimen within 6 months
2. Are there any expired drugs?

Yes / No If yes attach details

For preparation of QRPML at DTC-level, the TU reports are to be consolidated in the WRDR-DTC
format, which is available in Annexure V and also in the exercise given overleaf. WRDR-DTC
facilitates not only in correct consolidation of the TU reports and thereby helping in the preparation
of the DTC-QRPML but also ensures that quantities as per stocking norms get issued to the TUs.
WRDR-DTC: The data of all the TU reports shall be put in the WRDR-DTC format along with the
information of the stock register at the DTC drug stores. The DTC-QRPML comprises the total of all
the TU Reports & the DTC drug store. Prior monthly physical verification of the DTC-store is
essential for ensuring accurate reporting. However, to calculate Quantity Requested, No. of
patients initiated on treatment/3 x 7 minus total closing stock at TUs & DTC shall ensure that the
DTC receives its supply from its SDS as per stocking norms discussed above
An Exercise on the WRDR-DTC is available overleaf along with the format , Solution to the exercise
is placed at Annexure VI.

Exercise on District level Worksheet for Reporting Drug Requirement


(WRDR-DTC)
Data for PC-1 PWBs for all three TUs and the DTC, for the Quarter Ending Dec 2008 is provided
below. Please use the blank format available on the page overleaf, to prepare the WRDR, workingout the requirements of each TU, as well as the status/ availability of PC-1 PWBs in the District.
STOCKING STOCK STOCK
UNIT
ON
RECEIVED
FIRST
DURING
DAY OF THE QTR
QTR
(a)
(b)
(c)
TU 1
15
45
TU 2
13
48
TU 3
19
95
TU 4
47
143
TOTAL TUs
94
(A)
DTC Own (B)
127
253
TOTAL

DTC (District) 221


584
(A+B)

STOCK
RECONSTITUTION STOCK
TRANSFERRED OF BOXES DURING TRANSQTR.
IN
FERRED
OUT

PATIENTS
ISSUES TO
STARTED ON TU
TREATMENT/
CONSUMTION
DURING QTR
(h)
(i)
47
XXXXXXX
60
XXXXXXX
107
XXXXXXX
95
XXXXXXX

(d)
XXXXXXX
XXXXXXX
XXXXXXX
XXXXXXX

(e)
XXXXXXX
XXXXXXX
XXXXXXX
XXXXXXX

(g)
XXXXXXX
XXXXXXX
XXXXXXX
XXXXXXX

309

30

62

30

XXXXXXX

331

30

62

30

309

XXXXXXX

Please note that Issues from DTC shall be equivalent to Total Stock Received by all TU during the quarter from DTC.

171

Training Course for Program Manager


WORKSHEET FOR REPORTING DRUG REQUIREMENT (WRDR-DTC)
DTC:

For the Quarter Ending:

Drug:
Stocking
unit

Stock
on first
day of
quarter

Stock
received
during
the
quarter

Stock
Trans
fered
In

Reconstitution
of
boxes
during
quarter

Total availability of
drugs during
the quarter

Stock
Trans
fered
Out

Patients
started on
treatment/
consumtion
during
quarter

Issues
to TU

(a)

(b)

(c)

(d)

(e)

[f=(b+c+d+e)]

(g)

(h)

(i)

TU 1

XXXXX

XXXXXX

XXXXX

TU 2
TU 3

XXXXX
XXXXX

XXXXXX
XXXXXX

XXXXX
XXXXX

XXXXX
XXXXX

TU 4

XXXXX

XXXXX

XXXXX

TOTAL
TUs (A)

XXXXX

XXXXX

XXXXX

XXXXXX
XXXXXX

Stock
on last
day of
quarter

[j=f(g+h+i)]

Qty.
Requested
[for TU
K= (h/3*4)j]
[for dtc
(h/3*7)- j]
(k)

XXXXX

DTC
Own (B)

XXXXXXX

TOTAL
DTC
(District)
(A+ B)

State Level : Medication


Adult Patient Wise Boxes
Item

Unit of
Measure
-ment

Stock
on first
day of
Quarter

Stock
received
during
the
quarter

Stock
transferre
d in

Reconstituti
on of boxes
during
Quarter

Stock
Transferred
Out *

Patients
started
on
treatment

Stock on
last day of
Quarter

Quantity
Requested

(b)

(c)

(d)

(e)

(f)

(g)

(h)

(i)=(c+d+e+f)

(j)=(h/3 10)
-i

(a)

- (g+h)
PC-1

PWBs

PC-2

PWBs

Prolongation Pouches and Inj SM


Unit of
Measure
-ment

Stock
on first
day of
Quarte
r

Stock
receive
d
during
the
quarter

Stock
transfe
rred in

Reconstit
ution of
boxes
during
Quarter

Stock
Transfer
red Out *

Consumption
during the
quarter

Stock on last
day of
Quarter

Quantity
Requested

(a)

(b)

(c)

(d)

(e)

(f)

(g)

(h)

(i)=(c+d+e+f)
(g+h)

(j) =(h/3 10) i

Prolongation
Pouches

Pouches
each with
12 blister
strips

Streptomyci
n 0.75 g

Vials

Item

172

Training Course for Program Manager


Paediatric Patient Wise Boxes (Including PWBs for Adult Patients <30kgs)
PWBs

Stock
Stock
Consumption Stock on
Quantity
Unit of
Stock
Reconstitution
Stock
last day of Requested
Measurement on first received transferred
of during
Transferred during the
day of
during
quarter
Quarter
Quarter
in
Out *
Quarter
the
quarter

(a)

(b)

(c)

(d)

(e)

(f)

(g)

(h)

(i)=(c+d+e+f) (j)=(h/3 10)


-i
(g+h)

Paediatric PC 13 Boxes
Paediatric PC 14 Boxes
Pouches each
Paediatric PC 15 with 12 blister
strips

Pouches each
Paediatric PC 16 with 12 blister
strips

RNTCP Loose drugs


Stock
Stock on received
Stock
Reconstitution of
Stock
Unit of
Transferred
Measure- first day during transferred
boxes during
of Quarter
in
Out *
ment
the
Quarter
quarter

Item

(a)

(b)

INH 300 mg

Tablets

INH 100 mg

Tablets

Rifampicin
150mg

Capsules

Pyrazinamide
750 mg

Tablets

Ethambutol
800 mg

Tablets

(c)

(d)

(e)

(f)

173

(g)

Consumption
during the
quarter

Stock on last
Quantity
day of
Requested
Quarter

(h)

(i)=(c+d+e+f) (j)=(g/3 10)


(g+h)
-h

Training Course for Program Manager


For QRPML of State-level, the DTC reports are consolidated in the WRDR-State format,
which is similar to the WRDR-DTC except that TUs shall be replaced by DTC. As in case of
WRDR-DTC, a WRDR-State also facilitates in correct consolidation of the DTC reports and
thereby helping in the preparation of the State-QRPML and also ensures that quantities as
per stocking norms get issued to the DTCs.
WRDR-State: The data of all the DTC reports shall be put in the WRDR-State format along
with the information of the stock register at the State drug stores. The State-QRPML
comprises total of all the DTC Reports & the SDS. Prior monthly physical verification of the
SDS is essential for ensuring accurate reporting. However, to calculate Quantity
Requested, No. of patients initiated on treatment x 10 minus total closing stock at DTCs &
SDS shall ensure that the State receives its supply from its GMSD as per stocking norms
discussed above.
Additionally a monthly report from the State drug stores, format placed at Annexure VII is
required to be sent to Central TB Division latest by 7th of each succeeding month.
The Issues from States to Districts & from Districts to TUs is done through the State Issue
Vouchers ( SIVs ) & District Issue Vouchers (DIVs ) respectively. Format for these is placed
at Annexure- VIII.
4 (b) Monitoring:Monitoring logistics of drugs & other items is important to ensure:

Uninterrupted supply of drugs, consumables etc.,


Prevention of overstocking to avoid wastage of scarce resources leading to expiry of
high value drugs
Prevention of stock-outs to avoid delay in treatment initiation.

Monitoring drugs and logistics is done through a two-tier monitoring system: a central
system at Central TB Division (CTD) and a decentralized system by the State TB Officers
(STOs) and the District TB Officers (DTOs). CTD reviews and ensures drug adequacy at
State and district-level whereas the STOs and the DTOs ensures the same up to the level of
the DOT Centres. CTD ensures drug adequacy at districts by reviewing Quarterly
Programme Management Reports (QPMR) received from the districts which enables
continuous monitoring of drug stock position including verification of Reports giving the
details below:
Stock on the first day of the quarter
Quantity Received during the quarter (including reconstitution and transfers)
Patients started on Treatment during the quarter
Stock on the last day of the quarter
Quantity requested

174

Training Course for Program Manager

Maintaining adequate supplies

Monthly
Reports
GMSDs

CTD

Qtrly
Reports

Monthly
Reports
State Drug
Stores / STO

Qtrly
Report
s

Qtrly
Reports
Monthly
Report

PHI

Districts

TU

Monitoring cycle
Flow of Drugs: The flow of drugs is the direct reverse of the flow of reports. Drug
requirements, consumption and stock positions, both at State and district levels are
monitored at the Central TB Division through the quarterly reports submitted by the districts.
Regular, accurate monthly PHI Reports as well as their correct consolidation at the TUs &
District levels are hence, essential for correct monitoring of the stock position at various
levels.
Supply of drugs by Central TB Division from the GMSD to the SDS is communicated to the
State through a Release Order. Based on the district quarterly report, stock is supplied from
SDS to the district drug store to its TUs and then to the PHIs.
Hence, at the beginning, the PHIs are supplied with a stock of two months (ie. stock for
utilization in the first month along with a reserve stock of one month). Then every month, as
per the monthly PHI report, they are supplied with stock from the TU which helps to
maintain the reserve stock for a month at the PHI. This reserve stock helps the PHI to
provide drugs if more patients are put on treatment in a particular month and to provide
cover for delay in supplies from TU. Thus no patient is sent back due to lack of drugs even
on a single occasion.
For the TU level to ensure that the PHIs have a months utilization stock plus a reserve
stock of one month, it needs to have a reserve stock of two months at the beginning of the
quarter. This will ensure a continuous supply of drugs.
The regular process of supply of fresh stock of drugs from the GMSD to the SDS/districts
begins only when the districts submit their QPMR reports to the State/CTD (Epi-centre).
Once the QPMRs are received by Central TB Division, it takes around 7-10 days for CTD/
SDS to process the requirement (from all districts of all states). The district should have at
least a utilization stock of 4 months at the beginning of the quarter. Similarly the State Drug
Stores should have at least a reserve stock of 3 months of consumption of the state.
175

Training Course for Program Manager


During the first week of each quarter, TU, district and state will have to fill the format for
Quarterly Report on Programme Management and Logistics (QPMR). The data for this
report would be generated from the monthly PHI-level reports.
It is expected that buffer stocks shall also be ensured at each level as per the stocking
norms given in the table below.
Stock for
utilization
1 month

Reserve
stock
1 month

TU drug
store

0 months

2 months

DTC
drugstore

0 month

3 months

SDS

0 months

3 months

Level
PHI

Drug requirements
(Monthly consumption x 2) (existing stock in PHI
at end of the month)
(Quarterly consumption / 3) x 4 (existing stock in
TU including PHI drug stores at end of the
quarter)
(Quarterly consumption / 3) x 7 (existing stock in
DTC drug store including TU & PHI drug stores at
end of the quarter )
(Quarterly consumption / 3) x 10 (existing stock
in SDS including stocks at all districts at end of
the quarter)

Thus the quantity of reserve stocks and total stocks at each level at the start of the quarter
(considering the receipt from one higher level) should be as follows:Level
PHI
TU drug store
DTC drug store
State drug store

Utilization
1 month
-

Reserve stocks
1 month
2 months
3 months
3 months

Total stock
2 months
4 months
7 months
10 months

The above described movement of drugs can be further explained in the following manner:GMSDs
SDS

DTCs

TUs

PHIs

Quarterly (on basis of R.O from Central TB Division


based on the state/ district PMR)
Quarterly (Drugs are issued to the districts after
analysis of the District QPMRs. At the same time
drugs are received from the GMSDs by the 2nd
month of the running quarter)
Quarterly (Drugs are issued to the TUs after analysis
of the TU quarter reports. At the same time, DTC
receives drugs from the SDS by the 2nd month of
the running quarter)
Monthly (Drugs are issued to the PHIs based on the
PHI monthly reports. At the same time, TU receive
drugs from the DTC at the beginning of the
subsequent quarter).

176

Training Course for Program Manager


Criteria for identification of short expiry Patient Wise Boxes (PWBs)
There may be instances when the stores may have some short-expiry drugs. It is important
that proactive measures be taken to ensure transfer of such drugs to other districts/states to
prevent expiry of such batch of drugs. The DTO shall inform the State requesting for an
approval for transfer to other districts. The table below explains how to identify short-expiry
drugs in the stores.
Months
Item

Duration of
treatment

PC-1
6
PWB
PC-2
8
PWB
* At the district level

Extension
in IP

Possible
Interruption

Max transit
time for
shifting of box

At risk of
expiry, if less
than *

12

14

Note:
Loose drugs can be used till the last date of expiry ie. Drugs with DOE of Dec-09 can be
used till 31st Dec-09
5. Quality Assurance of drugs
Maintaining quality of drugs remains a critical programme requirement. This is enabled
through a system of pre-dispatch & post-dispatch testing of drugs and monitoring of the
quality throughout their shelf-life up to consumption by the patients. The following steps
have been taken by the Programme in ensuring best quality drugs:

At the time of Procurement: Stringent Quality Assurance requirements (WHO-GMP


certification) have been laid down under RNTCP. First line Drugs are procured from
WHO Pre-qualified pharmaceuticals & Second line drugs through ICB from WHOGMP compliant suppliers. A Pre-dispatch inspection of all batches is undertaken
prior to their dispatch from the factory premises.
Post-Procurement: Samples are lifted from various sites as per protocol developed
by the programme. These samples are picked up randomly from the GMSDs, SDS
& District level, each quarter and tested by an Independent Quality Assurance Lab
engaged by RNTCP. Additionally, quality is also monitored by State & Central Drug
Inspectors independently.

Reconstitution
Partially used boxes in case of defaults, failure, transferred out and death of a patient are
sent to district tuberculosis center and are reconstituted. Partially used boxes are at the risk
of expiry if they are not reconstituted. This should be performed at the DTC and carried out
under the direct supervision of the DTO. Complete information about failure, default, death
and transferred out cases, including TB number, name of PHI and number of blisters
remaining unused in the category wise boxes should be made available and recorded in the
Reconstitution Register(RR), format as in Annexure IX maintained at the DTC level.
The Reconstitution Register contains several columns wherein the details / number of
remaining IP/CP blister from partially used boxes are to be put in the respective columns at
the end of each quarter or as & when the reconstitution exercise is to be taken up. At the
177

Training Course for Program Manager


end of the quarter, if the number of blisters combipacks available, is good enough for
reconstitution of a PWBs of new or previously treated cases, then the number of Boxes
along with category shall be mentioned in the respective column. The number of
reconstituted boxes should then be entered in the drug stock register as receipts and
reported in the district QRPML. Such reconstituted boxes should be ideally used only at the
DTC PHI.
There may be instances where drugs for reconstitution may not be sufficient and run the
risk of expiry. In such cases multiple combinations viz. conversion into Prolongation
Pouches etc may be done as these can be used within a month. Alternatively, they may be
used as loose drugs to avoid expiry
Date of Expiry of the drug having shortest expiry in the box must be clearly marked on all
new labels of the reconstituted boxes. New boxes should never be used for purpose of
reconstitution. However, prolongation pouches may be used for reconstitution of the
incomplete boxes.
Additional Drug Request (ADR)
The need for an Additional Drug Request, format at Annexure - X arises only if the patients
put on treatment in the previous month in a quarter goes up, resulting in an insufficient
stock in the district. To get the additional supply from CTD/ State Drug stores (SDS), an
Additional Drug Request for each item (on separate page) needs to be submitted by the
DTO. Before sending the request ADR to CTD or SDS, districts should consider and track
the drugs that have been already released and are being transported from state/central
stores to the district.
Drug Logistics for Second Line Anti-TB Drugs
Guidelines for second line drug logistics management has been prepared by CTD &
circulated to the DOTS-Plus implementing States.
HIV positive TB patients who are on second line ART
Information on the need for Cap Rifabutin (150mg) for HIV positive TB patients who are on
second line ART or ART containing Protease Inhibitors should be provided by the in-charge
of ART Center providing second line ART (Centres of Excellence) to the DTO. The State
TB Officer needs to procure Cap Rifabutin (150mg) at state level and supply to the
concerned DTO/ART Center on a case to case basis. The DTO would ensure that Cap
Rifampicin from the PWB should be replaced with Cap Rifabutin in such cases. MO-PHI
should sensitize the DOT provider regarding the changes made in the PWB and monitor the
same.
Procurement Management Information System (ProMIS) Software
Empowered procurement Wing (EPW) of the MoHFW has developed web based software
(ProMIS) to streamline procurement systems and it has addressed all the key components
of International best practices in procurement and logistics. The various modules of the
software include Forecasting, Planning, Bid Processing, Bid Evaluation, Supply Orders,
Quality Assurance, Stocks, Inter warehouse transfers, Bills & Invoices etc. Data entry for
RNTCP drug stocks has commenced in many states & districts.

178

Training Course for Program Manager


(II)

LOGISTICS OF OTHER ITEMS


a. Treatment-related supplies - Weighing scales for adults and children, water
containers and disposable tumblers for DOT-centres
b. Lab consumables (reagents, sputum containers, slides, universal containers for
C&DST etc)
c. Forms, registers and reports etc
d. Binocular Microscopes (BM)
e. Four-wheelers, two wheelers, photocopier, computer and peripherals, etc

a) Logistics Management of Treatment-related supplies


Sufficient no. of water containers and disposable tumblers be made available at the
DOT centres for providing DOT. It is very important for every health facility that
administers treatment under RNTCP to have an adequate supply of sterile water,
disposable needles and syringes for giving streptomycin injections. The requirements of
these items should be matched with those of Injection Streptomycin vials. Remember
that each re-treatment patient, who is put on PC-2 PWB, would require 24 vials of
Injection Streptomycin. Ensure that there is a sufficient supply of cotton and methylated
spirit so that injections are always given under sterile conditions.
b) Laboratory consumables
Sputum containers and slides
To keep health facility and microscopy laboratories supplied with sputum containers and
slides, calculate the number of sputum containers needed for diagnosis and follow-up
examinations in each quarter. Then determine the number of slides needed. Place an
order for the sputum containers and slides with the appropriate source. Visit each health
facility that collects sputum specimens and microscopy laboratories to make sure there
is an adequate stock of sputum containers and slides.
Calculation of requirement of sputum containers
During the first week of each quarter, calculate the quantity of sputum containers your
district will need for that quarter. The following steps are required for this calculation:
1. Determine the number of new smear-positive cases registered and treated during the
last quarter. Use the Quarterly Report on New and Retreatment Cases for this.
2. Determine the quantity of sputum containers needed for diagnosis as described below:
Multiply the number of new pulmonary smear-positive cases by 10. The number of
smear-negative, extra-pulmonary, and retreatment smear-positive cases should not be
considered, because 10 symptomatic cases include all types of patients and because
patients with failure and default are examined as follow-up. Ten is the average number
of symptomatic required to be examined for detecting one case of New pulmonary
smear-positive tuberculosis (including a smear negative X-ray positive case).
Multiply the number obtained in Step 2 by 2. (2 sputum specimens are taken for each
symptomatic patient.)

179

Training Course for Program Manager


3. Determine the number of sputum containers needed for follow-up examinations. Followup specimens are taken for the majority of smear-positive patients on 3 separate
occasions during their treatment (at the end of the intensive phase, 2 months into the
continuation phase and at the end of treatment). Two sputum containers are needed for
each follow-up examination because 2 sputum specimens are taken for each follow-up
sputum examination.
For each pulmonary smear-negative case, follow-up sputum is taken twice. Hence,
multiply the number of pulmonary smear-negative patients by 4 (2 sputum samples each
at the end of the intensive phase and at the end of treatment).
The number of sputum containers for the examination of patients who remain sputum
smear-positive at the end of 2 months and of retreatment patients who remain sputum
smear-positive at the end of 3 months is not calculated. This number is usually very
small and the reserve stock and provision meant for wastage will cover this requirement.
.
4. Add the number of sputum containers needed for diagnosis to those needed for followup examinations. After you determine the number of sputum containers needed for
diagnosis and follow-up examinations, add these numbers to obtain the approximate
number of sputum containers required for the quarter.
5. Allowance for reserve stock: Allow sufficient reserve stock for 3 months.
6. Account for wastage: Add 10% to account for wastage of sputum containers.
7. Account for the sputum containers in stock.
On the last working day of the quarter, count the number of sputum containers presently
in stock. Then, during the first week of the new quarter, subtract the number of sputum
containers in stock from that needed for diagnosis and follow-up examinations as
calculated (Step 5).
Calculation of requirement of slides
There should be approximately the same number of slides in stock as sputum
containers, because one slide is used to examine one specimen in a sputum container.
Therefore, once you have determined the number of sputum containers needed for the
next quarter, order the same number of slides. There may be a need for slightly more
number of slides than containers because of unavoidable breakage of slides.
Order for sputum containers and slides
After you have calculated the number of sputum containers and slides needed for your
district, order the supplies. Order the sputum containers during the first week of the
quarter so that the health units and microscopy laboratories have enough sputum
containers to collect sputum specimens and the DMCs have enough slides to conduct
sputum smear examinations. In the RNTCP, these supplies will be procured by the
State/District It is important that good quality slides, containers and reagents are
purchased.

180

Training Course for Program Manager


Distribution of sputum containers and slides
After you receive the supply of sputum containers and slides for the quarter, distribute
the sputum containers to all peripheral health institutions in the district. The supply of
sputum containers to those PHIs that are not functioning as sputum collection centres or
DMCs would facilitate follow-up examinations because patients can be provided with the
same for morning samples. Reserve stocks should be maintained at all levels.
Ensuring adequate supply of sputum containers and slides
When you visit the PHIs, check the supply areas for an adequate stock of sputum
containers and slides. Ask the health workers or laboratory technicians if they think the
stock is sufficient. Estimate if there is enough stock to last until the end of the quarter,
and if there is sufficient reserve stock.
Universal Containers and CPC for Culture & drug sensitivity testing:For diagnosis and follow up of MDR TB, DTO should indent Universal Containers and
Cetyl Pyridinium Chloride (CPC)1% & NaCl 2% from the respective IRL, as per
requirement.

EXERCISE
In this exercise you will calculate the number of sputum containers and slides needed by a
district for the current quarter.
According to the Quarterly Report on New and Retreatment Cases, Thane District began
treatment of 80 New pulmonary smear-positive cases, 20 9retreatment (smear-positive)
cases and 60 pulmonary smear-negative cases last quarter. There were 125 sputum
containers and slides currently in stock in the beginning of the quarter.
Calculate the number of sputum containers and slides needed for the quarter.
Answer the following questions:
1. How many sputum containers should you order for Thane District?

2. How many slides should you order for the district?

181

Training Course for Program Manager


c) Forms, registers and reports
As you have learned throughout this course, there are several tuberculosis forms,
registers and reports used in the district.
Forms, registers & Reports
Forms
Lab form for sputum examination
Referral for treatment form
TB Treatment card
TB identity card
TB transfer form
WRDR forms (for District/TU)
Additional Drug Request (ADR) form
EQA Forms and Annexures
Form for Honorarium to DOT Providers
*Request form for C& DST
*Drug-o-gram forms
*Referral for treatment form for MDR TB
Registers
Lab Register
TB register
Referral for Treatment Register
Supervisory register
Stock registers (for capital assets)
Stock registers (for lab consumables)
Stock Registers for Drugs
Register for Quality Control Slides
Registers for RBRC coding
Indent issue voucher book
Reconstitution register
Log book for vehicles
Petty and main cash books
Accounts Ledgers
DOTS Directory (regularly updated)
Tour diaries
*Culture & DST Register
Reports
Supervisory checklists
Monthly tour reports and advance tour
programs
Quarterly reports
Monthly PHI-reports
Statement of Expenditure, audit reports,
utilization certificates
Physical verification report
Internal Evaluation report

Person responsible for maintenance of


records/forms/reports
Medical Officer and Lab Technician
Medical Officer
Medical Officer
Medical Officer, DOT-Provider
Medical Officer
District TB Officer/ MOTC
District TB Officer/ MOTC
District TB Officer
MOTC
Medical Officer
Medical Officer
District TB Officer
Lab Technician, STLS
Senior Treatment Supervisor
Medical Officer
Medical Officer
MO/Storekeeper
MO/Storekeeper
MO/Storekeeper
STLS/LT
District TB Officer
Pharmacist / Storekeeper
Pharmacist/Storekeeper
Officers / STS /STLS
Accountant / clerk
Accountant / clerk
Data Entry Operator
Supervisor
District TB Officer
Supervisor
Supervisor
STO, STDC, DTO, MO-TC, STS & STLS
MO-TC, MO, STS, STLS
STO/DTO/Accountant
Verifying Officer
IE team

182

Training Course for Program Manager


Determine once a year the number of all forms, registers and reports your State/district will
need during the following year. Make sure there is an adequate supply of all forms,
registers and reports within your State/district and sufficient funds are available for the
same as per norms.
The number of forms, registers and reports required is calculated as below:
During the first week of each year, calculate the number of forms, registers and reports your
State/district will require for that year. There are three steps for this calculation:

1. Determination of the number of forms, registers and reports your State/district


will need for the year.
The number of Tuberculosis Treatment Cards needed depends on the number of
patients treated for tuberculosis in the previous year. Use the four Quarterly Reports on
New and Retreatment Cases for the previous year to determine the number of patients
treated for tuberculosis. Multiply by 2 to allow for a duplicate card to be kept by the
multi-purpose health worker.
Approximately one Tuberculosis Register is needed each year for each sub-district.
Approximately one Tuberculosis Laboratory Register is needed for each microscopy
centre in the district each year. If some pages of these registers remain blank at the end
of a year, it can be used the following year. However, begin from a new page every
year.
Approximately 15 copies of the Laboratory Form for Sputum Examination are needed
for each pulmonary smear-positive tuberculosis case treated. For diagnosis,
approximately 10 Laboratory Forms for Sputum Examination are needed. (10 is the
average number of symptomatics for each case of pulmonary smear-positive
tuberculosis identified.)
For follow-up, approximately 3 Laboratory Forms for Sputum Examination are needed
for each pulmonary smear-positive tuberculosis case, and 2 Laboratory Forms for
Sputum Examination are needed for follow-up of each pulmonary smear-negative
tuberculosis case.
If you have access to a reference laboratory, a patients sputum specimen can be sent
for culture examination and if required, also to determine whether a patient is sensitive
or resistant to an anti-tuberculosis drug. The Mycobacteriology Culture/Sensitivity Test
Form contains a patients culture and sensitivity results. Medical officers should send
these through DTOs to C & S Laboratory with copy of the treatment card. Three forms
should be filled up for each referral.
Four copies of the Quarterly Reports are used each quarter. Keep one copy for the
district, send one copy to the STO, one copy to STDC and send one copy to the Central
TB Division. Since there are 4 quarters and 4 copies are used during each quarter, 16
copies of this report are needed each year.
Preferably, all these reports should be stored in electronic format at district and state
levels. These should be sent to all concerned levels through e-mail. You may avoid
excess and wasteful use of paper. However, it should be noted that districts and states
should have facilities for back-up of data in electronic format (CD-formats, etc) to avoid
183

Training Course for Program Manager


data loss due to virus attack and sabotage. The back-up materials should be kept under
safe custody.
Tuberculosis Transfer Form is completed when a patient is transferred to a health
facility in another district/sub-district.
Once a patient reports to a new district and is registered, the bottom portion of this form
is mailed back (or sent by other means) to the referring health facility. When the
referring health facility receives this portion of the form, they will know that the patients
treatment is being continued.
The number of Transfer Forms needed depends on the number of patients who were
transferred to another district last year. Add the total numbers in the transferred to
another district column for the four Quarterly Reports on the Results of Treatment for
the previous year to determine the number of patients who were transferred to another
district that year.
Three copies of the Tuberculosis Transfer Form are needed for every patient who is to
be transferred to another district next year. One copy each is given to:

The patient to be transferred, to hand over to the PHI where he reports for
continuation of treatment

The TB unit to which the patient is transferred

Office copy, to be retained at the transferring unit

Therefore, if 10 patients were transferred to another district last year, 30 Tuberculosis


Transfer Forms (10 patients x 3 copies per patient) would be needed for the following
year.
The Annexures I and II list the laboratory materials, tuberculosis forms and registers a
district needs for one year.

2. Add an extra 20% of the number of forms needed to take care of the increase in
tuberculosis cases or lost forms.
To account for the increase in tuberculosis cases and lost forms, add an extra 20% of
the number of forms needed. You do not have to make this calculation for the
Tuberculosis Register or the Tuberculosis Laboratory Register, because one of each
register should be sufficient for one year. Each TU will register approximately 150
cases/lakh/year x 5 lakhs = 750 cases/year. At least 1000 patients can be registered in
one register.
Initially, two registers are needed per TU so that there is no gap between the first and
second year of service delivery. The Tuberculosis Laboratory Register allows for
registration of at least 2000 patients. For each lakh, 75 smear-positive patients are
projected, requiring the examination of 750 patients . Additional follow-up examinations
will bring the number of registers needed to approximately one lab register / lakh.

184

Training Course for Program Manager

3. Account for the forms, registers and reports in stock.


On the last working day of the year, count the number of forms you have in stock. Then,
during the first week of the new quarter, subtract the number of each form in stock from
the total number of each form needed. This gives the total number of forms, registers
and reports required to be indented.
Distribution of forms, registers and reports
After you receive the supply of tuberculosis forms and registers for the year, distribute the
appropriate forms to the health units and the Tuberculosis Laboratory Register to the
microscopy centre. Keep the excess supply which is not distributed to the facilities in the
State/district to meet subsequent requirements of the health units during the year.
Printed materials
The districts should maintain an adequate supply of the following printed materials:

DOT Provider Guide Local language


MPW Module Local language
MO Modules with exercise books
Additional MOTC modules with exercise books
Facilitators Guide
RNTCP-At-A-Glance
Desk Reference (A4, single page color)
Modules for STS, STLS and LTs, with exercise books
Laboratory Manual for Sputum Smear Microscopy
Modules for training of Medical Practitioners (PPs/ Medical college faculty)
Technical and Operational Guidelines
RNTCP Laboratory Network guidelines for Quality Assurance of smear microscopy for
diagnosing TB
Strategy document on Supervision and Monitoring in RNTCP
*Guidelines for District TB Control Society
*Guideline for State TB Control Society
Guidelines for involvement of NGOs and PPs
Modules for HIV-TB Training
Key Facts and Concepts
RNTCP Brochure (blue cover)
Guidelines for Practicing Physicians
Guidelines for Medical Officers
RNTCP Procurement Manual
SOP Manual for District Drug Store
DOTS Plus guidelines
Other relevant document/guidelines as and where circulated out by CTD
Patient information booklet in local language
*These guidelines need not be printed. For reference, please refer to RNTCP website.
These printed materials may be printed at state-levels to ensure quality
at low cost.

185

Training Course for Program Manager

EXERCISE
From the information provided about the Birbhum District, list the types and number of
tuberculosis forms you need to order for this district to last throughout the next year.
Case: Birbhum District
In 2008, in Bolpur TU of Birbhum District, there were 220 tuberculosis patients, of whom
100 were diagnosed as new pulmonary smear-positive cases. There are 5 microscopy
centres in the sub-district. In this year, 8 patients from the sub-district were transferred to
another sub-district. Approximately 10 culture/sensitivity examinations were done in the
same year. At this time, you need to order tuberculosis forms and registers for 2009. The
following number of tuberculosis forms and registers are available in the reserve stock:
50. Tuberculosis Treatment cards
10 Transfer Forms
35. Tuberculosis Identity Cards
6 Tuberculosis Laboratory Registers
82. Laboratory Form for Sputum
3 Tuberculosis Registers
Examination
15. Mycobacteriology Culture/Sensitivity Test
Forms
Tuberculosis
Form/Register

Number
required

Add 20%

Subtract Stock

Net number

EXERCISE
1. What should be the reserve stock of drugs at the district level?
2. In Katurma District, 40 smear-positive cases were registered during the third quarter of
year 2008. Calculate the total number of sputum containers needed for diagnosis.
3. What is the basis for calculation of drug stocks?
4. What is the purpose of maintaining reserve stock?
d) Binocular Microscopes (BMs)
Sputum Microscopy is an essential part of RNTCP. It plays a major role in the
programme and hence procurement of BMs is an important component in RNTCP and
the procurement of binocular microscopes is undertaken by CTD and are delivered to
the States / Districts. All BMs should be covered by annual maintenance contracts by
states/districts, at the end of their warranty periods.

186

Training Course for Program Manager


Norms for supply of BMs
As per RNTCP guidelines, 1 BM is required for every designated microscopy centre
(DMC). One DMC exists for every 1 lakh population (0.5 lakh population in hilly, tribal
and difficult areas). In addition, RNTCP may also supply BMs to DMCs established in
other sectors like ESIS, Public Sector Undertakings, Medical College etc., if required.
BMs are also supplied by RNTCP to districts (depending on the number of DMCs/TUs)
for implementation of EQA.
(III) PREVENTIVE MAINTENANCE OF VEHICLES, EQUIPMENTS ETC
a) Vehicles
Vehicles are provided as per the financial guidelines of RNTCP. It should be ensured
that the vehicles purchased by RNTCP (4 wheelers and 2 wheelers) are in working
condition. This requires comprehensive annual insurance and regular & periodic
maintenance preferably through authorized workshops. Funds for the same should
be made available as per norms given in financial guidelines of RNTCP. Accessories
like helmets, rain coats, side boxes etc. should be provided along with two wheelers
for STSs/STLSs. Log books should be maintained for the vehicles.
b) Office equipments, Binocular Microscopes and equipments for IRLs.
All Office equipments, Binocular Microscopes and equipments for IRLs provided at
State/District levels by RNTCP need to be maintained through Annual Maintenance
Contract (AMC), utilizing funds available under the Programme. The details given in
RNTCP Financial Norms should be adhered to.
POINTS TO REMEMBER

Uninterrupted supply of drugs and other materials is critical to the success of TB Control
Programme.

Drug requirements are based on the number of cases, existing stocks, and reserve
stocks.

Maintenance of drug stock should be as per FEFO.

Reserve stocks are required to account for unexpected increase in TB case load, delays
in procurement and distribution of drugs, improper distribution of drugs, and pilferage of
drugs or lost due to improper storage.

Ensure regular physical verification of drugs and other materials at all levels.

Reserve drug stocks should be


2 months at TU, and 1 month at PHI level.

Ensure regular training of field staff on RNTCP drug logistics management.

AMC of BMs & IRL equipments and regular maintenance of vehicles should be ensured.

187

available

for

months

at

DTC,

Training Course for Program Manager


ANNEXURE I: APPROXIMATE LABORATORY REQUIREMENT FOR 3000 SLIDES FOR
SPUTUM SMEAR MICROSCOPY
Reagents/ Equipment for staining
Binocular microscope with 10x, 40x and oil immersion objective
(100x) eyepieces (10x) and spare bulbs and fuses
Plastic disposable sputum containers
Slides for microscope, 25*75 mm, 1.1 mm-1.3 mm thick
Broom stick 10 cms length
Diamond marker pencil
Timer, 30 or 60 minutes
Forceps, Chitel forceps stainless steel for slides 15 cm
Scissors, 25 cm stainless steel
Slide rack, Staining slide rod of metal or plastic or glass for 12 slides
Slide boxes, For 100 slides

Quantity
Atleast 1 per DMC

3,300
3,300
3,300
1 number
1 number
1 number
1 number
2 numbers
33 boxes + 1-2 per
DMC for RBRC
Tissue rolls
4 numbers
Grease marking pencil
12 numbers
Absorbent cotton, 500 gms/ roll
4 numbers (2 k.g)
Pressure cooker, For disposal by autoclaving
Optional
5% phenol
600 litres
Methylated spirit
3 liters
Aprons
2
Disposable gloves, 6 and 8 inches (box of 25 pairs)
12 boxes
Spirit lamp,
1 number
Metal wire, For swab for heating of Carbol fuchsin
1 number
Sputum specimen transport box, Insulated box, made of plastic 10 x 2 numbers
10 x 10, thickness 1 with lid, handle and nylon belt 1 width 2.5
feet length, nylon strap of 1 width 2 feet length with Velcro to strap
the lid of the box from side to side.
For preparation of reagents at DTC/TU
Reagents/ Equipment for staining
Basic fuchsin, Pararosaniline hydrochloride, C19 H18 N3 Cl, molecular
wt: 323.8, Colour: Metallic green, Dye content: Should be available
on the container. Approximately 85%-88%
Carbolic acid (Phenol), C6H5OH, and molecular wt: 94.11, Melting
point: 400C, Solidification point: 40.50C, Purity: 99.5%
Sulphuric acid: H2SO4, molecular wt: 98.08, Purity: 95-97%, Colour:
Clear
Methylene blue, (Methylthionine chloride), C16H18CIN3S, molecular
Wt: 319.9 Dye content: Should be available on the container.
Approximately 82%
Alcohol (absolute)
Funnel, 7 dia 7 height and 5 stem height
Funnel, 3 dia 4 height and 5 stem height
Drop bottles, Glass/ plastic 100 ml capacity
Bottles for storage of stock solutions, Brown bottles
188

Quantity
300 Gms
2 ltrs
10 ltrs
32 Gms
3.2 ltrs
4 nos.
4 nos.
8 nos.
4 nos.

Training Course for Program Manager


2 litre capacity
Flat bottom round flask, Capacity 3 litres of pyrex of glass
Wash bottle, Plastic 500 ml
Drop plastic bottle for immersion oil, 10 ml capacity
Disposable bucket, Plastic foot operated 12 liters
Measuring cylinder, 1000 ml capacity plastic or glass
Measuring cylinder, 100 ml capacity plastic or glass
Water tanks, Plastic with tap, 100 liters where there is no running
water facility.
Filter paper, Whatman no. 1 packs of 100 2 * 2
Adhesive labels for sputum containers
Soap, soap box towel and clean rags as needed
Aluminum vessel, for the purpose of carbol fuchsin solution
preparation 16 diameter 9 height
Water bath, for the preparation of carbol fuchsin
Beaker, 250 ml with spout
Display board
Distilled water (instead of distillation apparatus)
Stove wick type/ Bunsen burner with butane gas cylinder/ burner
with gas cylinder

5 nos.
6 nos.
2 nos.
2 nos.
4 nos.
4 nos.
1 no
1 box
6 rools
As per requirement
1 no.
1
1 no.
1 no.
35 liters
1

Laboratory reports and records


Laboratory form for sputum examination
Tuberculosis laboratory register

2200
2

189

Training Course for Program Manager


ANNEXURE II:
NUMBER OF TUBERCULOSIS FORMS AND REGISTERS NEEDED IN THE RNTCP
Names of tuberculosis forms and registers
Tuberculosis Treatment Card
Tuberculosis Identity Card
Tuberculosis Register
Tuberculosis Laboratory Register
Laboratory Form for Sputum Examination
Mycobacteriology Culture/Sensitivity Test Form

Number needed

2 per patient
1 per patient
1 per year per TU
1 per year per microscopy Centre
15 per new pulmonary smear-positive
case
Number determined by State tuberculosis
Officer
16 per year (4 copies x 4 quarters) for
each TB Unit and for DTC
16 per year (4 copies x 4 quarters) for
each TB Unit and for DTC
16 per year (4 copies x 4 quarters) for
each TB unit and for DTC

Quarterly Report on New and Retreatment


Cases of Tuberculosis
Quarterly Report of Sputum Conversion of New
Cases, Relapses and Failures
Quarterly Report on the Results of Treatment
of Tuberculosis Patients Registered 1215
Months Earlier
Quarterly Report on Programme Management PHI: (3 copies x 12 months) x No. PHIs in
and Logistics
district
Sub-districts: (2 copies x 4 quarters) x No.
TUs in District
District: (4 copies x 4 quarters) copies
Tuberculosis Transfer Form
Based on proportion of patients who were
transferred out of the district during the
preceding year. Estimate 1 for 20
patients.
Supervisory register
As per No. of PHIs
Referral for treatment forms
As per requirement
Referral for treatment register
1 each for Medical College, big Hospital,
etc.

190

Folio No. :

29.11.08

DTC - C

DTC-B

DTA- 68

IV-14

IV-35

8.11.08

1.11.08

AB

EF

AB

XY

CD

AB

XY

SIV 3 29.11.08 CD

SIV 2 26.11.08

12.11.08

SIV 1 17.11.08

SIV 1 17.11.08

Nov-10

Oct-10

Dec-11

Oct-10

Aug-10

Nov-10

Oct-10

Aug-10

10

50

60

40

40

20

10

20

60

100

90

110

120

70

10

10

10

10

40

40

60

60

60

10

50

50

50

50

50

10

10

10

Notes:
1. Use a separate sheet for each drug item
2. PHIs shall receive their stock requirements each month from their respective TUs.
3. In the case of Loose Drugs, report Consumption of Drugs During Quarter in column (h) instead of Patients Started on Treatment During Quarter
4. Issues from TU shall match with the total of stocks received by all PHCs, serviced by the TU.

26.11.08

17.11.08

SDS Delhi

DTC A

17.11.08

25.11.08

15.11.08 GMSD Mumbai

10.11.08 GMSD Karnal

DTC-A

1.11.08

Op Balance

PARTICULARS OF RECEIPTS & ISSUES

Unit of Measurement (UOM): PWBs*

RECEIPT ISSUE BALANCE DATE-WISE EXPIRY DETAILS SIGNATURE REMARKS


(Qty.)
(Qty.)
(Qty.)
OF BALANCE (Qty.)
OF STOREDate Name of Party Receipt Issue Date of Batch Date of
Expiry Expiry Expiry Expiry KEEPER
(Dd/
(GMSD/ SDS/ Voucher Voucher Issue
No. Expiry
Date
Date
Date
Date
No. (For No.(For Voucher
mm/ yy)
DTC/TU)
(Aug- (Oct- (Nov- (DecReceipts Issues
of Tran10)
10)
10)
11)
only)
only)
saction
(Receipt/
Issue)
(a)
(b)
(c)
(d)
(e)
(f)
(g)
(h)
(i)
(j)
(k)
(l)
(m)
(n)
(o)
(p)
(q)

SL.
NO.

Drug Item: PC-1

STOCK REGISTER (SR)

SOLUTION TO STOCK REGISTER EXERCISE:

ANNEXURE - III

Stock on
first day
of
the
quarter

Sock received during the quarter

Total Stock
Received
during the
Qtr.
[f=(c+d+e)]
Month 3
(i)

Xxxxxxxx

(j)

Total
Stock
Received
during the
Qtr.
[i=(g+h+i)]

Xxxxxxxx
Xxxxxxxx
Xxxxxxxx
Xxxxxxxx

(k)

Issues to
PHIs

(l)

Stock on
the last
day
of
quarter
[I=(b+f-jk)]

Xxxxxxxx

(m)
Xxxxxxxx
xxxxxxxx
Xxxxxxxx
Xxxxxxxx
Xxxxxxxx

Quantity
requested
for Total
TU: (i/3 x
4)-I]

4. Issues from TU shall match with the total of stocks received by all PHCs, serviced by the TU

2. PHIs shall receive their stock requirements each month from their respective TUs.
3. In the case of Loose Drugs, report Consumption of Drugs During Quarter in column (h) instead of Patients Started on Treatment During Quarter

Notes:
1. Use a separate sheet for each drug item

* Total Drug stocks shown as 'receipt by the TU s' should match with the Total drugs shown as 'Issued to TU s' at the district level.

Month 2
(h)

Patient started on treatment/


consumption during quarter

For the Quarter Ending:

Month 1
Month 2
Month 3
Month 1
(a)
(b)
(c)
(d)
(e)
(f)
(g)
PHI 1
PHI 2
PHI 3
PHI 4
Total
Stock at
PHIs
TU
on
stock
position
Total
Stock
position at
TU
PHI shall receive their stock requirement each month from their respective TUs.

Stocking
Unit

Name of Drug:

Medical Officer - TU

Worksheet for Reporting Drug Requirement (WRDR - TU)

ANNEXURE - IV

XXXXXXXX

TU 3

(e)

XXXXXXXX

XXXXXXXX

XXXXXXXX

Reconstitution
of boxes during
the quarter

Drug:-

(f)

Total availability of
drugs
during the
quarter (f
= b+c+d+e)

XXXXXXXX

XXXXXXXX

XXXXXXXX

(g)

Stock
transferred
out

(h)

Patients
started on
treatment/
consumption
during quarter

DTC:-

XXXXXXXX

XXXXXXXX

XXXXXXXX

(i)

Issues to
TU s

(j)

Stock on
the last
day of
quarter [
j = (f - g h- i)]

XXXXXXXX

(k)

Quantity
requested
[for TU: (h/3
x 4) j] [for
total DTC:
(h/3 x 7) -j]

Notes:
1. Use a separate sheet for each drug item
2. In the case of Loose Drugs, report Consumption of Drugs During Quarter in column (h) instead of Patients Started on Treatment During Quarter
3. Issues from TU shall match with the total of stocks received by all PHCs, serviced by the TU

TU 4
XXXXXXXX
XXXXXXXX
XXXXXXXX
XXXXXXXX
TOTAL
stock
position at
TU s
XXXXXXXX
XXXXXXXX
XXXXXXXX
XXXXXXXX
DTC Own
stock
position
*
XXXXXXXX
TOTAL
stock
position at
DTC
*
* Total Drug stocks shown as 'receipt by the TU s' should match with the Total drugs shown as 'Issued to TU s' at the district level.

XXXXXXXX

(d)

TU 2

( c)

Stock
transferred
in

XXXXXXXX

(b)

(a)

Stock
received
during
the
quarter

TU 1

Stock
on first
day of
the
quarter

Stocking
Unit

For the Qtr Ending:

WORKSHEET FOR REPORTING DRUG REQUIREMENT (WRDR)-DTC)

ANNEXURE - V

584

221

30

30

XXXXX
XXXXX
X
XXXXX
X
XXXXX
X
XXXXX
X

(d)

STOCK
TRANS
FERED
IN

62

62

XXXXXX

XXXXXX

XXXXXX

XXXXXX

XXXXXX

(e)

RECONSTITUTIO
N OF
BOXES
DURING
QUARTE
R

897

472

425

190

114

61

TOTAL
AVAILABILITY OF
DRUGS
DURING
THE
QUARTER
[f=(b+c+d+e)
]
60

30

30

XXXXX

XXXXX

XXXXX

XXXXX

XXXXX

(g)

STOC
K
TRAN
S
FERED
OUT

309

XXXXXXX

309

95

107

60

47

(h)

PATIENTS
STARTED
ON
TREATMENT/
CONSUMTIO
N DURING
QUARTER

DTC: For the Quarter Ending: Dec 2008

331

331

XXXXXXX

XXXXXXX

XXXXXXX

XXXXXXX

XXXXXXX

(i)

ISSUES
TO TU

227

111

116

95

[j=f(g+h+i)]
13

STOCK
ON LAST
DAY OF
QUARTER

494

198

296

31

136

79

50

(k)

QTY.
REQUESTED
[FOR TU
K=(h/3*4)-j]
[FOR DTC
K=(h/3*7)- j]

Notes:
1. Use a separate sheet for each drug item
2. PHIs shall receive their stock requirements each month from their respective TUs.
3. In the case of Loose Drugs, report Consumption of Drugs During Quarter in column (h) instead of Patients Started on Treatment During Quarter
4. Issues from TU shall match with the total of stocks received by all PHCs, serviced by the TU

*Total drug stocks shown as 'receipt by the tu's should match with the total drugs shown as 'issued to tu s' at the district level.

253

143

127

47

TU 4

95

331

19

TU 3

48

45

(c)

STOCK
RECEIVED
DURING
THE
QUARTER

94

13

TU 2

TOTAL
TUs (A)
DTC Own
(B)
TOTAL

DTC
(District)
(A+ B)

15

(b)

(a)

TU 1

STOCK ON
FIRST DAY
OF
QUARTER

STOCKING
UNIT

Drug: PC-1 PWBs

SOLUTION TO WRDR - DTC EXERCISE:

ANNEXURE VI

Training Course for Program Manager

ANNEXURE - VII : MONTHLY STOCK STATEMENT (MSS) OF STATE DRUG STORE

(Report Showing Receipts & Issues of Anti-TB Drugs as on


Name of State:

Month:

Sl.
No.

Item

UOM

(a)

(b)

1
2
3
4
5
6
7
8
9
10
11
12
13

PC-1
PC-2
Prolongation Pouches
Rif-450mg
INH-100 mg
Pza-750 mg
Inj-SM 0.75 g
INH-300 mg
Eth-800 mg
PC-13
PC-14
PC-15
PC-16

PWB
PWB
Pouches
Caps
Tabs
Tabs
Vials
Tabs
Tabs
PWB
PWB
Pouches
Pouches

Opening
Receipts
Balance Receipts Drugs
During Trfd. In
the Month
(d)

(e)

(f)

Total
Stores
(g =
d+e+f)

ISSUES
Balance
Stores
Store
Drugs
with
DOE
Supplied Trfd. Out
(h)

(i)

[j = g-(h+i)]

KEY: UOM: Unit of Measurement


Note: In the case of Inj. SM, please maintain stock at the rate of 24 injections for each PC-2 PWB in
stock

195

PC-1
PC-2
Prolongation
Pouch
Inj SM 0.75 g
Rif 150 mg
Pza 500 mg
INH 100 mg
Etha. 800 mg
INH 300 mg

Vials
Capsule
Tablet
Tablet
Tablet
Tablet

(c)
PWB
PWB
Pouch

(d)

QUANTITY
ISSUED

(e)

(f)

(g)

(h)

BATCH DATE OF STORES REGISTER STORES REGISTER FOLIO


NO.
EXPIRY
FOLIO NO. OF
NO. OF RECIPIENT
ISSUER

_______________________________
Signature of Recipient Storekeeper
__________________________
Signature of Recipient Officer

________________________________________
Signature and Stamp of Transporter (for SIV)

(i)

REMARKS

Notes:
(1) Stores Register Folio No. is to be given both by the issuer and recipient of drug stocks and comprises the page number of the Stock Register on which the issue/
receipt is recorded (2) Signature and stamp of the storekeeper/ authorized signatory of both the issuing and the recipient unit are to be provided in the SIV/DIV.

_________________________
Signature of Issuing Officer

____________________________
Signature of Issuing Storekeeper

KEY: UOM: Unit of Measurement; LR: Lorry Receipt; RR: Railway Receipt; ST: State Transport Receipt

3
4
5
6
7
8

1
2

(b)

(a)

UOM

(3) LR/ RR/ ST No.(for SIV):...

(3) SIV/DIV Date ..


(4) Issue Authorization Document: WRDR/ADR/ DTA/ ..
with Date of Approval.

Name of Item

(2) Name of Transporter: (for SIV)....

(2) SIV/DIV No. .

S. NO.

(1) Dispatched By (Name of SDS/DTC)

(1) Issued To (Name of DTC/TU)

(4) LR/ RR/ ST Dated (for SIV):..

Dispatch Particulars:

Issue Particulars:

ANNEXURE - VIII : STATE/ DISTRICT ISSUE VOUCHER (SIV/ DIV)

Total
Transfer of
PP stock from
Stock
Register Folio
Reconstituted
Regimen for
new cases
Reconstituted
regimen for
previously
treated cases
Total

(c)
Opening
Balance

DOT/PHI
(from which
drugs have
been
transferred

(d)

TB
Register
No.

(e)

Treatment
Regimen
(New/Previously
treated)

(f)

IP of New
cases (24
Blister
Combipacks)

(g)

(h)

Previously
treated
cases

New
Cases

(i)

Input (No. of Blisters)


(Unused blisters)
IP o
PP (12
CP of
Previously Blisters
regmen for
treated
in each
new cases
cases (36
PP)
(18 Multi
Blister
blister
combiCombipacks)
packs)
CP of
regimen
for
previously
treated
cases (22
Multi
blister
Combi
packs)
(j)
(k)

(l)

(m)

Output (No. of Boxes)


(Reconsituted)
Reconstituted Date of
Stock
Drugs
Expiry
Register
Folio No.

KEY: Treatment regimen for new/previously treated cases; IP: Intensive Phase; CP: Continuation Phase
1. Reconstituted IP & CP need to be put in poly bags with stickers on them, clearly mentioning that they comprise reconstituted IP or CP Pouches
2. DOE of the reconstituted Box to be reported in Column (l) shall comprise the DOE of drugs used having the latest DOE
3. Any loose drugs generated in the process may be used for patients put on non-DOTS treatment, or otherwise
4. Reconstitution should be done under supervision of the DTO every quarter. DTO may instruct for reconstitution at shorter intervals, if required

30.11.10

30.11.10

31.11.10

(b)

(a)

1
2
3
4

DATE

s.
No.

ANNEXURE IX
RECONSTITUTION REGISTER (RR)

Training Course for Program Manager


ANNEXURE X

ADDITIONAL DRUG REQUEST (ADR)

PLEASE USE BLOCK LETTERS:


Name of State/ District: ________________________________________________________
Full Name of STO/ DTO: __________________________________________________________
Office Phone of STO/ DTO, if any. (Pl. include STD Code): ______________________________
Office Fax/ E-mail ID of STO/ DTO, if any: __________________________________________
Residential Phone of STO/ DTO, if any: ______________________________________________
If none of above available, Phone No. at which message can be left for STO/ DTO: ____________
Complete one sheet for each item for which additional medicines or reallocation of medicines is
requested. For example, if you are requesting additional patient-wise boxes for new or previously
treated cases, then complete one sheet each for the same.
Treatment regimen requested for (tick one):
PC-1 PWB

PC-2 PWB

Prolongation Pouches

Isoniazid-100mg

Rifampicin-150mg

Pyrazinamide-750mg

Inj.Streptomycin-0.75g

PC-13 PWB

PC-14 PWB

PC-15 PP

PC-16 PP

List Quantity of This Item Received in Previous and Current Quarter:


Date Received

Total Number Received

Stock Position on Last Day of Previous Month


Total Balance of the Unused
Item on-hand at DTC
Drugstores (a)

Total Balance of the Unused


Item
on-hand
at
TU
Drugstores (b)

Total Balance of the Unused


Item on-hand in PHIs (c)

Total Balance of the Unused


Item on-hand in the Entire
District (d=a+b+c)

Utilization of the Item for the Entire District in Previous Month:____________________________


Request for Additional Requirement of Drugs: I request ___________units of ____________________ [item].
This will be sufficient for _____________________ months.

Signature of STO/ DTO: ___________________________ Date: __________________

198

Table of Contents
Module 8
Program Supervision and Evaluation
Learning Objectives .....................................................................................
Introduction .................................................................................................
Objectives of supervision ............................................................................
Preparation for supervision visit ..................................................................
Discussion with medical officers and health workers ..................................
Review of record .........................................................................................
Observation ................................................................................................
Examination of supplies ..............................................................................
Problem solving ...........................................................................................
Modalities of supervision .............................................................................
Maintenance of supervision record ..............................................................
Points to be remember ...............................................................................
Annexure I ................................................................................................
Evaluation ...................................................................................................

201
201
202
203
204
204
205
206
206
208
209
211
213
220

Training Course for Program Manager

MODULE 8
Program Supervision and Evaluation
Learning objectives:

Objectives of supervision
Supportive supervision: principles and process
Preparation for supervisory visits
Conducting supervisory visits
Problem Solving during supervisory visits
Operationalizing Supervision
Maintenance of Program Supervision records
Conducting Evaluation

Introduction
In the earlier modules, we have learnt about various activities that are to be undertaken to
diagnose and treat TB patients. These activities are performed according to the guidelines
of the program and require a combined effort of different categories of staff possessing
diverse skills at various levels of the health system. The scope of activities and operations
in RNTCP is large and involve not only multiple processes but also a large number of
human resources to implement and manage the program. In order to ensure that all
components of the program run smoothly, a well structured supervision strategy is key to
the success of the program
It is important to remember that supervision is an on-going process not just an event.
Supervision is a comprehensive exercise aimed at maintaining proper work
standards, building the capacities of the health staff and improving the deficient
areas using a constructive and practical approach. It also ensures replenishment of
supplies and stocks. Supervisory visits to health facilities give an opportunity to the
supervisor to review the performance and provide technical advice and guidance to the
health staff. This equips them to perform their activities correctly and confidently thereby
developing their knowledge, sharpen their skills and increasing their involvement in the
program activities.
Supervision is also accompanied by prompt corrective actions taken at the work spot. It is
to be remembered that it is not a fault finding mission. The health staff should feel
confident and find a guiding force in the team supervising the activities in the field.
Supervision should be performed at all levels of health system. Regular supervisory visits
should be conducted with emphasis on helping the health staff to identify and solve
problems. They also need feedback on their performance and encouragement in their work.
This will create a good working relationship among various categories of health staff and
.encourage a collaborative approach to problem solving.
A good supervisor is a FRIEND, PHILOSOPHER and GUIDE for his colleagues and
subordinates
Supervisory
visits give the health staff the opportunity to interact with higher levels. The
201

Training Course for Program Manager


interest shown by higher authorities during these visits can motivate people to perform their
best in achieving the goals. Most of the problems have local solutions. However the
problems that cannot be easily resolved by interacting with the health staff of the facility,
the matter is discussed with higher authorities, viz., District Tuberculosis Officer (DTO),
Chief Medical Officer (CMO), State Tuberculosis Officer (STO).

Objectives of supervision
The following are the objectives of supervision.

To build capacity of the health staff to implement the program procedures correctly.
To ensure that the data recorded and reported is accurate and valid.
To incorporate a system of analysis and review aimed at improving the quality of
programme implementation.
To increase the involvement and commitment of staff at different levels.
To provide actionable and timely feedback
To ensure equitable provision of services to all sectors of the community, including
vulnerable areas and marginalized population (urban slums, tribal / SC / Minority
pockets)
To evaluate the impact of training on the performance of health staff.
Assess re-training needs.
To assess the stocks and replenishment of supplies.

Supportive Supervision
The supportive supervision approach emphasizes on:

Constructive feedback,

Joint problem solving, and

Two-way communication between supervisors and those being supervised.

Process of Supervision

202

Training Course for Program Manager

Guiding Principles for supportive supervision:

Focus on processes and systems


Nurture effective communication with staff
Resolving conflicts
Involvement and ownership-of supervisor and those supervised.
Efficiency and delivery should be the target oriented
Continuous learning, development, and capacity building of those supervised
Reinforcement on quality health outcomes at all levels

PREPARATION FOR SUPERVISORY VISIT

1. Review of previous reports


Prior to undertaking the supervisory visit, monthly & quarterly reports and findings and
recommendations of previous supervisory visit(s) are to be reviewed.
2. Prioritization of sites
Based on the data from above mentioned sources, it is important to prioritize on the
sites to be visited and the key items to focus on during the supervisory visit.
As per guidelines discussed later, there is a need to visit different types of health
facilities at required intervals; some sites need more supervisory support than others.
However a decision on this is based on certain performance indicators derived from
various records and reports.
Criteria for identification of centers for intensive supervision

Extreme deviations from program indicators, such as :

Cure rate for new sputum smear-positive patients is less than 80%

Low suspects examination rate, low or high sputum positivity rate.

Low case detection of sputum smear-positive cases

High proportion of sputum negative and extra-pulmonary cases


Low proportion of patients receiving directly observed treatment

High proportion of patients initiated on inappropriate regimen

3. Preparation of Tour Programme


The visiting team has to prepare the travel plan well in advance to ensure availability of
all concerned members of the supervisory team. The format given in annexure -1 may
be used for this purpose:

4. Intimation of tour programme to the Health Centre


It is always advisable to notify the in-charge of the health facility about the proposed visit
so that the presence of the field staff can be ensured during the visit. Occasionally,
supervision can also be undertaken on a surprise visit to find out the factual situation.
Reasonable amount of time should be spent to ensure effective supervision. It should be
203

Training Course for Program Manager


ensured that the staff in the periphery should not get an impression that supervision is
being rushed through.
5. Prepare Supervisory checklist
A checklist of activities to be supervised in a centre proposed to be visited is prepared in
advance. (Refer supervisory check-list given at the end of this module) Since it may not
be possible to evaluate all the activities on a single visit, it is important for the
supervisory team to prepare their own checklist in continuation with observations made
during earlier visits. Review of previous reports is useful for identifying the priority areas
to be focused during the supervision

6. Supervisory Team:
Supervisory team should possess a mix of skills and competencies keeping in mind the
key areas and the sites to be visited.
II CONDUCTING SUPERVISION
Supervision is generally carried out with prior intimation to the concerned officials It can
also be undertaken as a surprise visit occasionally.
The supervisory visit should be conducted in an open and congenial atmosphere
encouraging two way communication and joint problem solving.
There are several ways in which the information could be obtained during the visit.
Identified priority areas will require a mix of approaches, some of which are mentioned
below:-

1. Discussion with Medical Officers and health workers


The knowledge and practices of the medical officers and health staff regarding their
tasks is to be assessed during the discussion. Inadequacies observed during such
interactions may be resolved by mutual consultation. Good work done by the health
staff should always be acknowledged

2. Review of records
Efficiency of the performance can also be assessed through review of important
documents. Records that should be reviewed include:

Lab register
Treatment cards
Referral for treatment form and register (if available)
Transfer form
Register for drugs and consumables
Register for supervisory visits
TB register

The information entered in more than one record is compared and checked for consistency.
For example, the results of sputum examination are entered in lab register, treatment card
and TB register. Random checking of such information in various records should be done to
204

Training Course for Program Manager


ensure consistency. Any inconsistencies that are observed should be discussed with the
concerned personnel. Good record keeping practices should be appreciated.
The following records and reports are cross-checked for consistency:

TB register, lab register and treatment cards


Monthly PHI-level report and lab register
Monthly PHI report and register for drugs and consumables
Monthly PHI-level report and quarterly programme management and logistics report
Quarterly reports and TB registers

3. Observation
a) Observation of activities
On-site observation of various programme activities during their actual performance
is one of the most effective tools for supervision. The activities at DMCs and DOT
centers may be observed closely to assess the adherence to the programme
guidelines. Immediate feedback should be provided on the work performed. While
the correct practices should be acknowledged, any deviations observed should be
communicated with the intention of improving systems and processes rather than
targeting the individual .
b) Observation of Interaction between health staff and patients
Observing interactions between MO/Health staff and patients is crucial for
understanding how the programme is functioning and the areas that require
improvement.

At Health Centre:
Observing the interactions during various activities like sputum collection, DOT,
health education, etc. will help the supervisor to understand the information provided
to the patients and the manner in which it is provided. The supervisory team should
take note of the following:

Health staff behaves politely with the patients.


The health education messages conveyed should be simple and clear.
Instructions to the patients are communicated clearly to the patients for
example, correct way of bringing out sputum, adherence to treatment
regularity, cough hygiene, etc

Home visit : Interaction with the patients and their families is crucial to gauge

patients understanding of the disease he/she is suffering from and the course of
treatment to be followed. This also provides an indication of the quality of health
service delivery. Selection of patients to be visited at their home will be at the
discretion of the supervisory team. However, smear positive patients and patients
who have interrupted the treatment should be given preference. It would be
preferable if the in-charge of the health facility accompany the team during home
visit. Feedback on the observations made during the supervisory visit should be
205

Training Course for Program Manager


provided to the concerned health staff. Information obtained during the patient
interview should be cross-checked with the available records.

4. Examination of supplies
The following items are to be checked to assess the adequacy:
Drugs
Needles and needle cutters
Syringes
Ampoules of water for injections
Sputum containers
Laboratory consumables

Laboratory forms for sputum


examination
Tuberculosis Treatment Cards
Tuberculosis Identity Cards
Tuberculosis Transfer Forms
Referral for Treatment forms
Supervisory Register

Equipments are checked for their functional status. Reagents are checked for date of
preparation and expiry. Patient-wise boxes are also checked. It is to be ensured that drugs
and reagents with earlier expiry date are used before the stock with later expiry date. Drugs
or consumables should not be kept beyond their date of expiry. During supervisory visits,
unused portions of patient-wise boxes of patients who have defaulted, died or transferred
out are to be taken back to DTC. The partially consumed boxes are not to be re-used for
any other patient, as this may result in incomplete treatment. However the unused blister
packs will be used for reconstitution at DTC.
The stock of drugs and lab consumable is cross-checked with monthly PHI- reports and
registers, followed by physical verification of the existing stock.
Recording feedback on supervision
Observations and recommendations arrived at during the supervision should be entered in
the register meant for supervision. Besides, a report on feedback of supervision should be
sent promptly to the health centre visited for corrective actions. Higher authorities may be
furnished with a brief report for any administrative intervention if needed. Feedback and
problem solving are key to effective supervisory activity.

Problem solving
Problem solving is one of the important objectives of supervision. The steps for solving
problems are described below.

Step 1
Description of the problem identified during supervision by answering these questions

What is the problem?


Where does the problem occur?
With whom does the problem occur?
When and how often does the problem occur?
When did the problem start occurring?
206

Training Course for Program Manager

Step 2
Possible causes are identified by answering these questions

Whether the person is aware of the responsibility and has been told to complete the
task?
Does the person have the skill or knowledge to do the task assigned?
Is the person willing to do the task?
Are there obstacles preventing the person from doing the task?

Step 3
Identify and implement the solutions. The specific solution depends upon the cause(s) of
the problem. Solutions that one arrives at should be:

Removable / reducible of specific causes:


Realistic, reasonable and affordable
Not creating other problems.

Group Discussion for problem solving


The problems identified and the possible solutions could be discussed as a team. The steps
mentioned above may be followed during the discussion.

Exercise
Problem identified

STS has reported that he has recently found about 30% cases who have previous history of
anti-TB treatment for more than 1 month are receiving treatment regimen for new cases in a
certain PHC.

207

Training Course for Program Manager

MODALITIES OF SUPERVISION
The recommended modalities for supervision by different categories of staff are presented
in the table below:
Supervisor

Methodology

DTO/MO
DTC

MO-TC

Frequency

Conduct interview with health staff and


RNTCP key staff and other sectors
Conduct interview with health staff of
Private/NGO hospitals
Interact with community and local
opinion leaders
Randomly interview patients and
community leaders.
Inspect records of the TU, PHC and
CHC, and stock of anti-TB drugs and
laboratory consumables.
Randomly check the microscopy centre
and DOT Centers

Visit all TUs every month and all


DMCs every quarter.
Visit all CHCs and Block PHCs in
the district every quarter, one
sub-centre from each Block PHC
area and a proportion of
treatment observation centres
every quarter.
Conduct supervisory visit at least
3-5 days a week. Visit at least
three patients at their homes per
visit
Visit identified private/NGO and
other sector health care centres.

Interview the MO I/C Block


PHC/CHC/PHC./Private/NGO hospitals
Randomly interview patients and
community leaders.
Interact with community and local
opinion leaders
Randomly check the microscopy centre
and DOT Center
Stock of anti-tuberculosis drugs and
laboratory consumables.

Visit all DMCs every month.


Visit all CHCs/BPHCs/ PHCs and
a proportion of treatment
observation centres at least once
every quarter.
Conduct supervisory visits 7days
a month.
Visit at least three patients at
their homes per visit.
Visit identified private/NGO and
other sector health care centres.

STS

STLS

Interview MPHS and MPWs at the PHC


sub-centre.
Inspect records, Tuberculosis Treatment
Cards and Tuberculosis Laboratory
Register.
Randomly interview patients.
Interview health staff of identified
Private/NGO/other sector health care
centres

Visit all PHIs at least once every


month and all DOT centers once
every quarter.
Visit all sputum positive patients
at their home within one month of
treatment initiation.
Conduct supervisory visits at
least 5 days a week.
Visit identified private/NGO and
other sector health care centres.

Inspect all microscopy centres , review


laboratory records, check stocks, inspect
sputum collection centres and PHIs
including that of private/NGO and other
sectors

Visit all microscopy centres in the


jurisdiction of the TU at least
once a month.
Visit all sputum collection centres
at least once a month.

208

Training Course for Program Manager

MAINTENANCE OF SUPERVISION RECORDS


Each health facility should maintain a supervisory register for recording the observations
made by the supervisor /supervisory team. The supervisor / supervisory team should record
the findings and the corrective actions recommended to be taken. Documentation of the
observations will facilitate taking prompt corrective action at different levels and help the
supervisor reviewing the same in subsequent visit. The supervisory register is filled up in
triplicate One to be retained as office copy, the other for the supervisor for review in the
subsequent visit and the last copy to be sent to higher authority for information and
corrective actions.
Supervisory Report format: The supervisory report would be in the following format:
Report of Supervision
Name of health facility:
Name of the supervisor:
Persons interviewed:
Activities
Observed -Please
focus on the
following areas:

Date & time of visit:


Designation :

Problems identified

Administrative (
HRD and Financial)
Diagnostic, Drugs
and Lab
consumables ,
DOTS and Follow
up, Records and
Reports, IEC/
ACSM,PPM)

Recommendations
with persons
responsible and
Time frame
Follow up actions
taken, based on
the previous
recommendations
Name and
Signature of
supervisor
Comments from
Program Manager
(DTO/STO)
Date :

Name and Signature

209

Training Course for Program Manager

EXERCISE 1
1. What are the main objectives of supervisory visits?

2. How would you prioritize health facilities for supervision?

3. What methods are used by the DTO/MO-TC for supervision?

4. What is the frequency of supervisory visits conducted by the DTO&MO-TC?

5. Which microscopy activities should be checked during a supervisory visit?

6. Which treatment activities should be checked during a supervisory visit?

7. What aspects of drug supply and stores should be checked during supervisory visits?

8. Which type of patients get the highest priority during supervisory visits?

9. Name the three most important records that must be checked and verified during
supervision?

10. Describe the steps involved in problem-solving during supervision.

210

Training Course for Program Manager

EXERCISE 2
In the following case studies, work with other participants to develop a checklist for a
supervisory visit. The facilitator will provide you with background information about the
health facilities.
Case Study 1
You have planned a supervisory visit to a designated microscopy centre. During your
preparation for the visit, you have found that the sputum positivity rate is low in the DMC.
Prepare a checklist to investigate this problem. What are the probable causes and
solutions?
Case Study 2
You have planned to visit a PHC. The STS has reported recently that low proportions of TB
cases are being administered directly observed treatment as per guidelines. Prepare a
checklist to investigate the situation. Suggest measures to solve the problem.

WORKSHEET FOR CHECKLIST

EXERCISE 3
Conduct a site visit to the health facility. The facilitator will explain the details of this visit.
Use the checklist you developed. After the site visit, there will be a group discussion on any
problems your group found and the solutions you recommend. Use the worksheet on the
opposite page to record your groups findings and recommendations. Your group will then
present its findings and recommendations to the other participants in the course.

Points to remember

The focus of supervision is on education, motivation, communication, feedback


facilitation with the overall objective of implementing corrective actions.
Supervision is the backbone of the programme.
Supervision helps in identifying the problems and solving them.
Supervision enhances the knowledge, hones the skills, instills right attitude and
improves motivation.
Supervision helps in ensuring proper work standards in terms of case detection and
treatment.
Supervision ensures replenishment of stocks and supplies.
Prioritization of centres for supervision depends upon: Low suspects examination/ case
detection rate, cure rate < 80%, default rate > 8%,
211

Training Course for Program Manager

The methods of supervision comprises discussion with health staff, observation of


activities, review of records, interaction with patients and their families, examination of
stocks, supplies and equipments for adequacy and functioning status.
Interaction with patients at their residence is an extremely important component of
supervision. This helps in validating the accuracy of RNTCP records. It also provides an
opportunity to address any concerns patients might have, and to counsel them to take
regular treatment.
Give priority to monitoring sputum smear-positive patients during your supervisory visit.
Tuberculosis Registers, Treatment Cards, and Laboratory Registers are the key records
to be reviewed during supervisory visits.
Feedback to the concerned health staff and to the higher authorities is an essential
component of supervision.

212

Training Course for Program Manager

ANNEXURE-1.
FORMAT FOR ADVANCE TOUR PROGRAMME
MEMBERS OF THE SUPERVISORY TEAM
(NAMES /DESIGNATIONS AND DUTY STATION)

1.
2.
3.
DATE:
Period
Place of visit
(Dates/From
- to)

Whom to visit

Purpose of visit (major activities


planned to be indicated)

RNTCP: SUPERVISORY CHECK-LIST


A. Diagnostic Aspects (Please write Yes/No in the column Observation )
No

Review of resources

Observations

Is at least one trained Medical Officer available in the health


facility?

Is a full-time trained Laboratory Technician (LT) available for


sputum microscopy?

Have provisions been made for sputum collection when LT is


absent?

Is a functional binocular microscope available?

Has the binocular microscope undergone any servicing during last


12 months?

Are all essential lab consumables available adequately, enough to


last at least for one month?

Is running water available for sputum microscopy?

Is electricity available for the binocular microscope?

Have civil works been done in the Lab as per RNTCP guidelines?

10

Are printed reference materials on standard operating procedures


available?
213

Training Course for Program Manager

Review of forms, registers, records and reports


1

Are the Lab Forms for Sputum Exams filled correctly, completely and
legibly?

Is the Lab Register filled correctly, completely and legibly?

Is the Lab Serial Number entered correctly, starting with 1 on 1


January of the year and continuing until 31 December?

Are results correctly recorded?

Are two sputum smears done for diagnosis for all pulmonary TB
suspects?

Are there two sputum smears done for follow-up for all eligible
patients?

Are positive results written as scanty, 1+, 2+ or 3+ in red and


negative in black/blue?

Are results up-to-date?

Does the Lab register have the summary abstract completed at the
end of each month?

10

Is there a duplicate Lab Register?

11

Are copies of supervisory reports of Senior TB Lab Supervisor


available at DMC?

12

Is there evidence of supervision by STLS on lab register?

13

Is monthly PHI-level report on sputum microscopy and logistics being


submitted by the health facility?

14

Does the Tuberculosis Register contain all the smear-positive


patients recorded in the Tuberculosis Laboratory Register? If the
Tuberculosis Laboratory Register contains names of smear-positive
patients which are not found in the Tuberculosis Register, do these
patients belong to another TU/district?

15

Is the Lab register consistent with the treatment cards and TB


register? (Check information for at least 4-6 randomly selected new
smear-positive patients.)

Observe the Lab technician during the sputum-collection procedure


1

Did the LT check to ensure that the Lab Form was complete and
correct?

Is the sputum container clearly labeled on the side and not on the lid?

Are each set of sputum samples from a single patient given a single
Lab Serial Number?

Is the Tuberculosis Number written in the space provided for all


patients whose reason for examination is follow-up of treatment?

Does the LT demonstrate to patients how to bring up sputum?

Does the LT supervise patients when they provide spot sputum


specimens?
214

Training Course for Program Manager


7

Does the LT visually examine the sputum provided to determine if it is


sputum or saliva only?

Observe the Lab technician preparing smears for examination


1

Does the LT use only new slides?

Does the LT engrave the Lab Serial Number on each slide with a
diamond marker?

Does the LT use a different broom stick for each sputum smear?

Are the sputum smears made on the slide of the correct size (2 cm x 3
cm) and thickness?

Does the LT wait for the slide to dry before heating the slide to fix it?

When the Lab technician fixes the slide by heating, does he do it for
the proper duration of time?

Is only freshly prepared carbol fuchsin being used, instead of readymade commercially-available solutions?

Is the carbol fuchsin free of particles and properly filtered at least


every month?

When the LT heats the carbol fuchsin, does s/he do it properly,


avoiding boiling and allowing the slides to stand for 5 minutes after
heating?

10

Does the LT tilt the slides after rinsing with water to remove excess
water?

11

Is the sulphuric acid allowed to stand on the slide for the appropriate
time period (24 minutes)?

12

Is the methylene blue allowed to stand on the slide for the appropriate
time period (30 seconds)?

Observe the Lab technician examining slides under the microscope


1

While placing immersion oil on the slide, does the LT take care to
avoid touching the slide with the applicator?

While examining the slide with the X100 lens, does the LT take care
to make sure that the lens does not touch the slide?

Does the LT examine negative sputum smear slides for at least 5


minutes?

Does the LT have correct knowledge about grading?

Does the LT see 100 fields before declaring the smear as negative?

Does the LT correctly complete the Lab Form for Sputum


Examination and Lab Register?

Does the LT clean the X100 lens with lens paper or fine silk after
completing the examination?

Are slides correctly cleaned and maintained serially in slide boxes for
review by the supervisor?
215

Training Course for Program Manager


9

Are all smear-positive results recorded in red ink in the Lab


Register?

10

After examining the slides, does the LT put the sputum containers
and lids (with lids removed) along with the broom sticks, into a footoperated bucket containing 5% phenol?

11

Does the LT break all the remaining slides of the previous month
after the EQA procedure is completed

12

Does the LT ensure that smear-positive as well as smear-negative


slides are not being re-used for AFB microscopy?

Exit-interviews of at least 2 patients undergoing sputum microscopy


1

Do the patients know how to cough out good quality sputum


properly?

Do the patients know when they should return for the next sputum
exams?

Do the patients find the timings and location of the Lab convenient?

Do the patients face any difficulties for undergoing sputum


microscopy?

B. Treatment Aspects
Sl
No

Review of TB Register

Observations

Is it numbered 1 from 1 January?

Are names and addresses readable?

Is the classification and outcome complete, correct and up-todate?

Are follow-up and results correct (Lab Number, slash if positive in


follow-up) and up-to-date?

Have pulmonary smear-negative patients been examined by


sputum microscopy?

Are quarterly reports correct?

Are Transfer Forms correctly filled and filed?

Are Referral forms correctly filled and filed?

Are all new patients who are smear-positive at the end of 5


months or more declared as Failure and re-registered as
previously treated cases?

216

Training Course for Program Manager


Sl
No

Review of Treatment Cards

Observations

Are the entries correct and legible?

Is the correct treatment regimen prescribed?

Is the intensive phase of treatment prolonged for one month for


patients put on treatment regimen for new cases and regimen for
previously treated patients who have positive sputum smears at
the end of the intensive phase?

Are Tuberculosis Treatment Cards maintained correctly and upto-date?

Is DOT administration done correctly?

Are follow-up sputum examinations done at the correct time?

Review the treatment of 5 smear-positive patients found to be


AFB smear-positive during follow-up examination. Was the
treatment correct?

Interview at least 3 smear-positive patients every field-visit day


Sl
No

Check-points

Is the patient aware that he/she is/was undergoing treatment for


TB? (Ask this question in private)

Does the patient know the correct duration of treatment for his
TB?

Was there any difficulty in accessing diagnostic facilities?

Did the treatment of the patient start within 7 days of sputum


microscopy?

Has the patient taken more than 1 month of anti-TB treatment in


the past?

Did the patient take all the 24 doses under direct observation in
the IP?

Is participating in DOT convenient to the patient in terms of


location?

Is participating in DOT convenient to the patient in terms of


timing?

Did the patient have to pay for sputum examination or drugs


under RNTCP?

10

Did the patient mention that he provided 2 sputum samples


before the start of treatment?

11

Did the patient mention that he provided at least 2 sputum


samples at the end of 2 months of treatment? Write NA, if this
question is not applicable due to default, etc. (Correlate with TB
register)
217

Observations

Training Course for Program Manager


12

Did the patient mention that he provided at least 2 sputum


samples at the end of treatment? Write NA, if this question is not
applicable due to default, etc. (Correlate with TB register)

13

Age of the patient (write completed age in years)

14

Sex of the patient (M=Male, F=Female)

15

Was the patient satisfied with the interaction and support


provided by the program staff?

16

Are the findings of the patient interviews consistent with TB


register?
Whether a duplicate treatment card is maintained at community
DOT centres and if so, whether original card is being updated
periodically?

17

Sl Interview and observe at least 3 DOT-providers


No
1

Is DOT being administered correctly?

Is retrieval action taken within one day during the intensive phase
and within one week during the continuation phase?

Are the Tuberculosis Treatment Cards completed at the same


time when treatment is given?

Is the DOT providers awareness regarding treatment and follow


up satisfactory?

Are sputum cups lab forms etc available with DOT providers?

Observations

Review organization of direct observation of treatment


Sl
No

Check-points

Are alternative resources for observation (community volunteers,


hospital staff, etc.) being used as necessary?

Are patient-wise boxes marked for each patient?

Do the amount of drugs in the boxes tally with those mentioned in


the Treatment Card?

Are sufficient stocks of drugs and other consumables available at


the Peripheral Health Institution (PHI) level?

Are water container and disposable glasses available at the


treatment observation centre?

218

Observations

Training Course for Program Manager


Sl
No

Inspect the drug storage area

Is it locked?

Are the shelves in place?

Is the inventory system in place?

Are drugs with an early date of expiry placed in the front?

Are all drugs kept off the floor and away from the wall?

Are there adequate drugs and other consumables in the store?

Sl
No

Observations

Checklist for HIV-TB intensified package


These information may be elicited from patients interview /
discussion with medical officer/ review of treatment card/ TB
register
Whether all TB patients are being referred for HIV testing?

Whether HIV status has been recorded in the treatment card?


Number negative and number positive?

Whether all TB-HIV patients are receiving CPT?

Number of TB-HIV patients on ART?

Sl
No

Checklist for MDR-TB management


These information may be elicited from patients interview /
discussion with medical officer/ review of treatment card/ TB
register

Whether all eligible MDR-TB suspects are being referred for


culture and DST?

Whether all MDR-TB patients diagnosed are referred to DOTSPlus site for initiation of treatment?

Whether all MDR-TB patients on DOTS-Plus receive the drugs


as DOT?

Is there a system in place for identifying and managing side


effects with MDR-TB treatment?

219

Observations

Observations

Training Course for Program Manager

EVALUATION
Program Evaluation refers to assessing the efficacy of the program on identified
parameters. Evaluation is closely linked to the process of supervision and share similar
objectives of addressing deficient areas and improving the quality of overall program
implementation
Evaluation is being done at state level and central level on a periodical basis with members
from other state, adjacent district, representatives from national institutes and Central TB
Division.
Besides, Government of India along with the WHO organizes evaluation of the programme
by international panel of experts from the field of public health, TB research and treatment,
medical education and other related sectors. This is undertaken as joint monitoring mission
once in three years.

Internal Evaluation
Intensive supervision and monitoring at all levels is critical to the success of the RNTCP.
The state level Internal Evaluation (IE) is a tool for comprehensive review of the programme
in a district with the purpose of giving specific recommendation to improve the programme
performance. The objectives of IE of the districts by the state are as follows:
1. Validation of the cure rates of the district with reference to the last quarter reported;
2. Assessment of the programme performance as well as financial and logistics
management;
3. Recommendations for improving the quality of recording and reporting and
4. Recommendations for improving the performance (with a time line)
The State TB Officer has the overall responsibility of coordinating the IE. The members of
the IE team comprise of various state level and district level officials. The DTOs of
neighboring districts are also invited to be a part of the team as this facilitates the exchange
of experiences. Similarly members from the local medical colleges can be invited to
participate in the IE team. Representatives of NGOs and other partners who are trained in
the programme and also in IE protocol can also be part of the IE team
The States are expected every quarter to select two districts for internal evaluation, based
on the latest quarterly reports. Ideally the districts selected should be one well performing
district and one poorly performing district. In states where there are less than 4 districts
implementing RNTCP, then 1 district per quarter may be evaluated, alternating the
selection of district in each quarter. The STO is expected to send the names of the districts
planned for IE, along with the proposed dates of the evaluation to the Central TB Division.
The detailed IE protocol has been circulated to all the states. In brief, the focus is on
interviewing patients, the District TB Officer and his team, to identify issues, which need
improvement, and collectively recommend the course of corrective action.
Designated Microscopy Centres and DOT Centres are selected for evaluation depending
on certain criteria given in the protocol. Subsequently a number of patients, mainly new
sputum smear-positive pulmonary TB cases, are visited and interviewed. Also a sample of
re treatment patients, pediatric patients, MDR-TB patients and TB/HIV patient if available
220

Training Course for Program Manager


are also interviewed. Patients are interviewed regarding the diagnostic and treatment
services. TB lab register, Treatment cards and TB register are cross checked for verification
of data. Standardized formats have been developed for the recording of the data for patient
interviews and for cross checking of the records.
Additional information can be elicited by discussion with DTO, Medical Officers and other
supervisory staff of the district and observation of DMCs and DOT-Centres in the districts.
The IE team, under the leadership of the STO, provides a detailed feedback to the DTO
and the district authorities, and sends a copy of their IE report to the Central TB Division.
Points to Remember

Internal Evaluation is a useful tool for comprehensive review of the programme. It is


not a fault finding mission.
State IE team will have members as STO and STC team, Director STDC and team,
DTOs, Consultants, members from Medical colleges, NGOs etc.
States should evaluate two districts every quarter.
IE team to provide feedback on IE conducted to key programme staff
Districts to send action taken report on the recommendation in IE.
State IE report and action taken report from districts to be copied to CTD.

221

Table of Contents
Module 9
Managerial Skills for TB Program Managers
Learning Objectives ................................................................................................................
Use of management in revised NTCP ....................................................................................
Discipline of management ......................................................................................................
Basic functions/roles ...............................................................................................................
Key Management challenges .................................................................................................
Managerial style .....................................................................................................................
Key task for program manager ...............................................................................................
Difference between a manager & leader ................................................................................
The importance of situation ....................................................................................................
Managerial skills for effective program manager ....................................................................
Key learning points of communication ....................................................................................
Build a team ...........................................................................................................................
Managing staff performance ..................................................................................................
Feedback ...............................................................................................................................

225
225
227
227
228
228
230
232
234
235
237
238
240
241

Training Course for Program Manager

Module 9
Managerial Skills for TB Program Managers
Learning Objectives
In this section, the participants will learn about the following:
Overview of the discipline of Management
Human Resource Management
Key Management Challenges
Managerial Styles of effective TB Program Managers
Key Tasks of TB Program Managers
Key Skills of Program Managers
a) Communication
b) Team building
c) Building partnerships
d) Managing performance
Conclusion
Use of Management in Revised National Tuberculosis Control Program
Tuberculosis continues to be a major public health challenge for India, complicated further
by the emergence of multi-drug resistant TB and TB- HIV co-infections. It has therefore,
become critical, more than before to ensure the provision of quality services through well
managed national TB control program to meet these challenges.
It is in order to meet a felt need to enhance the management and leadership skills within the
National TB Control Programs that a module specifically addressing these issues has been
developed within the RNTCP Modular training package for program managers.
The successful control of TB will largely depend upon the strength of TB control activities at
all levels. Strong management of healthcare facility and hospital staff is imperative for the
implementation and adequate TB control activities.
From a public health perspective, poorly supervised or incomplete treatment of TB is worse
than no treatment at all. The problem however cannot be attributed to just lack of an
effective treatment, but to a lack of systematic and structured management mechanisms to
address all components of the program.
As a program grows, its important to ensure that anyone in a managerial position,
particularly those at line/program manager level, have a good understanding of the
application of management principles of which HRD is a core component.
What is meant by Human Resource Development?
Human Resource Development (HRD) is set of systematic and planned activities designed
by an organization /program to provide its members with the skills and competencies to
meet current and future job demands.
Human resource development is a part of Human Resource Management and it deals with
the all round development of an employee within an organized framework from the time
they join the an organization to the time they leave.
225

Training Course for Program Manager


Why are HRD activities important for TB program managers
-

Increase productivity and quality outcomes of staff


Reduce learning time to reach performance and proficiency levels
Reduce performance deficiencies
Enhance employee commitment
Promote professional development

The focus of all aspects of Human Resource Development is on developing the most
superior workforce so that the program can accomplish its goals of universal access to TB
care. In the module, health workforce/human resources development is used
interchangeably. HRD in this context refers to the process of planning, managing, and
supporting the health workforce for comprehensive TB control within overall health
workforce development.
What should be the vision when we plan for Human Resource Development in our
area?
Vision
To achieve the ultimate goal of Revised National TB Control Program which is to ensure
universal access to TB care services through sufficient, competent, committed and
motivated human resource.
What should be the ultimate goal we would like to achieve when we strategize our
efforts towards effective management of human resource in our area?
Goal
To support human resources development for Revised National TB Control Program with a
view to develop a health workforce which is responsive and sensitive to health needs of the
population.
HRD and Universal Access
In order to strive towards universal access to TB care, it is imperative that Program
Managers take a proactive role for developing and supporting strategic approaches for
competence development of the staff and creating an enabling environment for all the staff
involved in RNTCP; as well as coordinating their efforts with overall health workforce
development.
Evidence is now available to demonstrate that the number and quality of workers are
positively associated with positive outcomes.

226

Training Course for Program Manager

Health interventions cannot be carried out without health workers. Developing a competent,
motivated and supported human resource is therefore essential for overcoming obstacles to
achieving national and global health goals. Therefore, it is the responsibility of every
program manager to take a challenging and analytical perspective on how people are
managed in the program.
Revised National TB Control Program envisages a paradigm shift in the role of program
officers at the district and state level from a purely clinical role to managerial role.
Following the widespread implementation of DOTS by national TB control programs in
several countries, it became increasingly clear that the major obstacles to TB control
programs were no longer only technical in nature. The running of a large national TB control
Program required increasingly better management, communication and leadership skills on
the part of the TB program managers at National and intermediate levels of the program.

Discipline of Management
Management in all organizational/program activities is the act of getting people together to
accomplish desired goals and objectives using available resources efficiently and
effectively. Management comprises planning, organizing, staffing, leading or directing, and
controlling the program or effort for the purpose of accomplishing goals or objectives

Basic functions/Roles
Management operates through various functions, often classified as planning, organizing,
staffing, leading/directing, and controlling/monitoring.i.e

Planning: Deciding what needs to happen in the future (today, next week, next
month, next year, over the next 5 years, etc.) and generating plans for action.

Organizing: making optimum use of the resources required to enable the successful
carrying out of plans.

Staffing: Job analyzing, recruitment, and hiring individuals for appropriate jobs.

Leading/Directing: Determining what needs to be done in a situation and getting


people to do it.
227

Training Course for Program Manager

Controlling/Monitoring: Checking progress against plans.

Motivation: Motivation is also a kind of basic function of management, because


without motivation, employees cannot work effectively.

Key Management Challenges


1. Project Management: This involves dealing with issues of developing better planning,
monitoring, controlling, and reporting progress on activities/interventions managed by
Program Managers. It also means challenges of evaluating trade-offs between resource
needs, time and cost in project management.
Additionally it includes analysis in terms of SWOT analysis (analysis of Strengths,
Weaknesses, Opportunities and Threats) for:

Availability of health infrastructure and resources

Socio-cultural-economic profile of community, geographical terrain, provision for


additional inputs in program, etc

Performance of the program (especially trends)

SWOT Analysis
Internal
assessment

Strengths

Weaknesses

External
assessment

Opportunities

Threat

2. Financial Management: This area poses challenges that focus on identifying various
parameters for budget preparation and evaluation of actual financial performance; to
design the appropriate management information system for periodic reporting of actual
results; and to take corrective action in order to ensure that the process of fund
utilization is efficient and effective.
3. People Management: A Program Manager has certain basic responsibilities such as
setting goals and objectives, planning, resource mobilization, supervision and
monitoring. However as a program manager, you also have a very important
responsibility of developing and motivating your staff. This is people management. As a
program manager you do this by interacting with your staff
Exercise 1 : Undertake a SWOT analysis of RNTCP in your respective state/ district.

Managerial Styles
Some of the key people management issues faced by most TB program Managers are:
-

Managing Staff performance- Handling non performance as well as high performance


Managing training / skills gaps in a planned manner
228

Training Course for Program Manager


-

Communication handling communication gaps , challenges, Involvement of key


stakeholders, content and frequency of communication , communication with outside
agencies, government bodies , other partners.
- Interpersonal Conflicts between program staff, between teams
- Staff Discipline
As a TB Control Program Manager, you influence your staff and colleagues with whom you
interact. Your role is not only to solve future problems and to help others, but also to have
an impact on their ability to solve future problems. Good managers achieve their program
objectives with and through their staff. You can develop your staff by building their capacity
to face challenges and resolve problems. Your way of providing guidance and interacting
with your staff or colleagues is called your managerial style.
There are different managerial styles and different managers have different ways of
interacting with their staff. Different situations may also require the use of variety of
managerial styles.

Managerial Styles for Effective Program Managers


Supportive Style: Managers act as supportive coaches providing support when required.
They not only encourage their staff to do things by themselves, but also let their staff know
that they are available, if help is needed. Managers with this style motivate their employees.
Prescriptive style: People with this style are critical of others behavior and develop rules
and regulations and impose them on others. Managers with this style make quick
judgments and insist that their staff should also follow. This style uses control and does not
encourage independent thinking or action.
Problem solving style: Here, a manager is concerned with solving problems by looking at
them from various dimensions. The manager deals with and finds solutions to problems by
involving staff or other appropriate people.
Task obsessive style: These managers are most concerned with the tasks. Matters not
directly related to the task are ignored .They are insensitive to the emotional needs and
personal problems of staff.
Assertive style: They are concerned with exploring a problem, often confronting the
organization to get things done for their staff. People with this style are more concerned
about confronting problems rather than confronting persons. Such people are frank and
open, but are equally perceptive, sensitive and respectful of others.
Aggressive Style: Managers with this style fight for their staff or their ideas by showing
aggression towards others. They hope that this will help them achieve the results. Their
aggressiveness makes people ignore them and not take them seriously.
As a manager you may use all the styles mentioned above . However you may use one
style more often than others. This is called your dominant style. The style you use the most
other than your dominant style is your back-up style.

229

Training Course for Program Manager


Discussion Analyze your individual managerial style , where do you personally fit
in and does it remain stagnant across situations. Which style according to you is
most effective in managing your program.

Managerial Style function of Subordinate Maturity


It is also relevant to note that the managerial style adopted by the Program Manager should
match the maturity of the subordinate. Maturity in this situational context is assessed in
relation to both psychological maturity and job maturity.
Psychological maturity refers to the self-confidence and ability and readiness to accept
responsibility of subordinates.
Job maturity refers to the relevant skills and technical knowledge possessed by
subordinates .
It is also believed that managers should be flexible and adjust their styles as followers and
situations change over time.

Managers need to manage the program as well as the people they work with.
Managerial style may change according to the situation and persons being dealt with
Managers have to adjust their style of managing depending upon the maturity level and
readiness of the sub-ordinates.

Key Tasks of Program Managers


The key tasks undertaken by the program managers are as under:
a)
b)
c)
d)

Strategic Planning
Organizing
Leading
Monitoring and Evaluation

1. Strategic Planning :
What is it ?
Strategic planning is a process used to build a plan about the most important goals your
program should achieve in the next few years . RNTCP makes Annual Action Plans
which includes all aspects of planning financial , program and manpower related
Why is it important ?
The planning process is important to make sure that the state responds to the changing
needs of its stakeholders and outside organizations and to make sure that everyone
knows what actions will lead to achievements they intend.
What is to be included ?
Strategic plans should include :
Goals for changes that will advance programs mission
Specific actions to achieve those goals in the defined time-frame
The priorities of those actions
A clear assignment of responsibility for carrying out those actions
230

Training Course for Program Manager


How to make Planning effective in your state:
1. Undertake systematic situation analysis
2. Set aside time for planning
3. Make a planning schedule or calendar : that includes dates to do the following :
a. Monthly review of the program direction and objectives
b. Adjusting objectives in line with the realities of the environment
4. Identify people involved in your planning
a. Who will participate
b. Who will approve
c. Who needs to be informed?
d. By obtaining understanding and acceptance
2. Organizing
a) Organize tasks and responsibilities
Organize tasks and responsibilities to departments according to the skills required to
accomplish them effectively and efficiently. Establish clear lines of authority and
accountability
b) Selecting people
Choose people for positions based on their ability to accomplish the task of
organization today and in the future.
3. Delegating
Entrust others with responsibility and authority and creating accountability
4. Developing effective teams
Form teams composed of people within departments or from several different
departments to identify problems or inefficiencies and propose solutions. Work toward
improving dynamics of teams.
5. Set standards of good work
Establish clear performance expectations for each job and each employee. Train and retrain employees to meet or exceed those standards consistently.
6. Recognizing
Acknowledging good performance is a very important part of managing performance.
7. Set policies , systems and procedures
Employees need to know how to perform tasks consistently to achieve the
organizations mission .Policies, systems and procedures are valuable training tools for
getting consistent results.

231

Training Course for Program Manager


4. Leading
A leader is a person who can influence the behaviour of others without having to rely on
force.
What is leadership ?
Leadership can be simply defined as the act of making impact on others in a desired
direction. He has positive attitude towards people and their work. He points the direction
and others follow. In short, effective leaders are supportive, self confident, and positive.
They are pathfinders, more divergent in their thinking and have futuristic vision.
Characteristics of a Leader
Although many characteristics have been listed as typical of leaders, four are of particular
note. Leaders:

Establish the direction visionaries


Align people communicate their vision and create teams to achieve it
Motivate and inspire energize people to overcome barriers by satisfying
basic needs
Produce change

Leadership styles
1. Autocratic Style
- Requires unquestioned authority
- Emphasizes structure and order
- Weakness : Can be abrasive when trust is not earned or when the issues or the
audience required another style
2. Participatory Style :
- Appropriate for consensus building
- Emphasizes creativity
- Requires setting authority aside
- Weakness : Can be time consuming
- Each participant has effective veto power
3. Collaborative style
- Appropriate for resolving conflicts
- Requires mutual respect and authority
- Emphasizes reasonable outcomes
- Weakness: Difficult to accomplish consistently

Differences between a Manager and a Leader


Manager:
A manager tends to be a problem solver, seeks better ways to deploy the resources to get
the job done.

232

Training Course for Program Manager


Leader:
A leader, on the other hand, is a pathfinder; he is more divergent in his thinking and
concerned with building the organization for future.
Leader and Manager Roles
S.N.

LEADER

MANAGER

Visionary

Planner, Organizer

Strategist

Controller

Politician/ Advocate

Supervisor

Campaigner

Monitor

Team Builder

Efficient User of resources

Change agent

Status quo

There is no one best leadership style


What one often finds is that as the situation or the people you are working with change, it is
necessary to adapt your leadership style. This is the basis of a style of leadership, termed
Situational Leadership
Exercise
We have all worked with leaders whose styles we have liked and others whos styles we
have not appreciated. List for yourself attributes that you perceive as likeable and those
that you perceive as disagreeable.
Positive leadership
style attributes

Negative leadership
style attributes

You may be surprised that some leaders with autocratic styles have accomplished a great
deal, while some affable and completely democratic leaders have accomplished very little.
It is clear that different styles and approaches of leadership are necessary in specific
situations and with specific people this is the basic thinking behind situational leadership.
233

Training Course for Program Manager

The Importance of the Situation

If the situation, or environment changes dramatically and the team member is faced with a
large scale emergency e.g. 20 cases of dengue in a hospital, then in that situation the team
workers may have the knowledge but no experience or skill, and their motivation may be
variable. Thus the situation may demand a different leadership style. A similar example is
a nurse who has mastered the principles of Polio has special strategies for reaching
merginalised communities and run very successful mass vaccination campaigns. However
she may not have been introduced to the DOTS programme and so still relies on only
monthly patient visits. You will need to modify your leadership style from delegating when it
comes to EPI to a more directive style for providing her with the right leadership to improve
her TB control.
4. Monitoring and Evaluation
Management is not complete without ensuring that monitoring and evaluation systems
are in place. The program manager needs to develop systems for checking on the
work of their team members to ensure that the desired results are achieved and to set
the stage for continuous improvement.

234

Training Course for Program Manager

Managerial Skills for Effective Program Managers


a) Communication Skills
b) Team Building
c) Building Partnerships
d) Managing Performance

Communication Skills
Communication is a part of every function of management, including management of health
services. Good communication enhances managerial and leadership skills, as well as
personal and role effectiveness. It promotes transparency and harmony in the work
environment, leading to greater involvement of staff and effective team and partnership
building.
As a TB Program Manager, you will need to communicate with a variety of people both
within and outside the TB Program. This section deals with interpersonal communication
with your staff to ensure that the work is carried out effectively.
Communication is the flow (transmission and reception) of information, ideas, feelings,
attitudes and perceptions both verbally and non-verbally, between two or more parties.
It embodies attitudes, behavior, body language, style, method of presentation, quality of
listening and perceptions and interpretations
.
Communication involves at least two people a sender or source and a receiver .
Communication takes place for a purpose, is expressed as a message and sent through a
channel from the source to the receiver. The receiver picks up the message, interprets it
and then responds. Communication can be thought of as a process or flow; communication
problems occur when there are blocks in that flow.
Understanding can occur only in receivers mind . A person may be listening, but not
necessarily understanding what may be said. Many managers overlook this fact when
giving instructions or explanations. They think that telling someone is sufficient. However
communication is only truly successful when the message is also properly interpreted and
understood. As per the figure

Transactional Model of communication


Channels of Communication
The most commonly used channels to communicate with staff are as follows:

235

Training Course for Program Manager


Organizational Channels:

Written communication : This type of communication becomes important when certain


guidelines /procedures need to be followed

Staff meetings: Meetings may be called in to give staff an opportunity to exchange


information, solve problems and to give instructions about a new skill that may need a
detailed explanation or demonstration.

Training courses: These are held to update the knowledge and skills of staff.

Lectures or seminars: These are held to introduce and explain new concepts,
procedures etc.

Interpersonal Channels
Managers often communicate orally with staff members on one-on one basis, to discuss
good or poor performance to motivate and counsel them, to discuss and solve problems
arising at the workplace and to better understand the individual problems of the staff.
Written communication: should be precise, clear, unambiguous , and to the point to avoid
any kind of confusion. The feedback on written communication is rarely instant, in fact there
may be long delays in seeking clarifications.
In general, the language used must lend itself to easy comprehension and spoken or
written in a manner that reflects an understanding of sensitivities of the receiver.
Email Communication: When communication is sent through email , you must be very
careful to check , who else is the message copied to , in order to avoid embarrassment or
breach of confidentiality.
Oral Communication : To use this medium effectively , it is important that the talk is brief ,
or only as long as the need be and is prepared and structured in advance to include all the
points that must be said.

Barriers to Communication
The process of communication can be very complex with its various elements and
variables. There are a number of barriers that impede effective communication They can
come up at the level of the sender, the message, the channels of communication or the
receiver.
Communication barriers at Organization level
Physical Distance
An important barrier to effective communication, particularly in large organizations is the
distance between people, making messages difficult to send or receive, or misinterpreted.
Organizational Policy and Culture
Organizational Policy and climate also determine in what manner an employee is expected
to communicate. Staff at lower levels within the system may not communicate easily with
staff at higher levels and vice versa.
236

Training Course for Program Manager


Structural barriers
Each organization develops structures, rules and regulations for achieving its objectives.
There is a chain of command for reporting at various levels of authority based on principle
of unity of command.

Key learning Points in Communication

Communication is a two-way process through which we interact with each other


Effective interpersonal communication is essential for TB control Managers and is
important for every aspect of their roles/functions
Good communication enhances managerial and leadership skills , personal and role
effectiveness , helps team and partnership building.
One can improve ones interpersonal communication by being aware of the all the
above elements and by practicing them to avoid any obstacles in communication.

Team Building
As a TB Program manager one of your primary responsibilities is to develop an
effective team that works towards achieving the program goals. In your role as a
State TB Officer , you facilitate, motivate, and guide your team. You have to
transform a group of individuals into a team, by clarifying objectives, planning
operations with consensus, co-ordinating resources and getting things done
together, despite obstacles, stress and demanding pressures.
What is a team?
The term team is defined as a group of individuals working together for a common
purpose and goal with interdependent skills.
Four characteristics of a team
a) Team members must have a common goal and a reason to work together
b) Team members must perceive the need for an interdependent working
relationship
c) Individuals must be committed to the teams efforts and
d) The team must be accountable to a higher level in the organization
Teams are different from groups. A group is a collection of individuals who may not have
any of the four elements mentioned above. A team has the potential to accomplish much
more than the most efficient working groups that do not work as a team. A team leader
usually has a team leader who is responsible for what the team does as a whole and for
who does what within the team to achieve the objectives. The team leader is also a team
member.
As a TB Control Program team leader, you need to have the knowledge, skills and
capability to build a team as well as ensure that the team works together to achieve a
common goal. You would also need to adopt a managerial style that helps your team to
work more efficiently.

237

Training Course for Program Manager

Build a Team
Team building and development are important for several reasons
i.

As a tool for good management

ii. Stress among team members is reduced as problems are solved through sharing of
workload
iii. More innovative and creative ideas are generated, this improves team performance.
iv. Teams can solve complex, multi-interdisciplinary and interpersonal problems more
effectively than a group of individuals.
It is important for you as a manager to build an effective team in which various players (your
staff) work harmoniously together with an understanding of each others position, role, tasks
and capabilities. You as a manager need to focus on the following:
a.
b.
c.
d.

Setting goals and priorities


Deciding means and methods to work
Examining ways in which the team works
Exploring the quality of working relationships

You would also need to adopt a managerial style that helps your team to work more
effectively and efficiently
The success of a team is dependent on a common understanding among members of the
team of their roles and responsibilities. The team members should be clear on:
a. what their job is and how it relates to the work of others in the team
b. the work and duties of all team members. This is to avoid duplication,
overlooking of key tasks, or one person taking on too much.
c. how each ones role relates to the teams goals

What are Effective Teams?


An effective team is one that achieves its specific objectives in the most efficient way ,
making the best possible use of resources and in the shortest span of time. It is always in a
position to take up more challenging tasks. Such a team will have reached high levels on
the desired outcomes of each stage in the team building process.
An effective team is one in which team members give their opinions and comments without
hesitation (reducing the teams closed areas) listen to and examine opinions comments and
feedback given by colleagues at all levels (reducing the teams blind areas) and are
sensitive to the needs of other members in the team.
Yet another way of analyzing team effectiveness is to view the level of team empowerment
by looking at :

Clarity of roles within the team


Level of autonomy of the team
Support provided to the team in terms of resources
Accountability of the team to achieve the goals to which commitment has
been made.
238

Training Course for Program Manager


Important points to remember

As a Program Manager, you have to build your team which has complementary skills . This
will help you in achieving the objectives through your people
A team has the potential to achieve much more than a group of talented individuals not
working as a team
As a State TB Program Manager , your ability to build and lead a team is crucial to the
success of the program in your state

Building Partnerships
As a TB control Program Manager, you are aware that effective TB Control services can no
longer be a function of the public health system alone. Experience with planning
National TB Programs has led to the recognition that the public health sector alone cannot
meet the requirements posed by increasing case loads , while simultaneously tackling all
the cultural , social and economic factors that influence TB as a disease. For effective
implementation of DOTS Strategy and in order to increase the reach and application of
DOTS, it has become clear that it is necessary to identify and reach out to all the health
care providers in both public and private sectors and further to all stakeholders in the nonhealth sectors.
It is essential that patients, their families and communities are also included in the fight
against TB.
Partnership Mutuality
Partnerships among individuals and groups have four overlapping characteristics that
benefit all parties concerned:
Networking to share information
Co-operating to provide resources to each other for achieving common goals
Working collaboratively as individuals or teams towards these common goals
Joining forces as partners in a common mission to help one another, e.g. Private
Practitioners may help a TB clinic to conduct its activities. This is referred to as
partnership mutuality.
The TB Program is such where inter-sectoral partnerships could prove extremely useful in
program implementation as well as in policy making, planning, program evaluation,
advocacy and generating additional resources.
The following are the key aspects that characterize a partnership with the potential to build
a long term relationship:

Shared vision and commitment

A vision is a realistic idea that is desirable for the program and its members and can be
achieved through joint efforts. Commitment refers to contributing something of value such
as time, money, resources or moral support
There should be a common vision to which all partners are committed

239

Training Course for Program Manager

Super-ordination

An overall goal is important to all partners concerned, and should be one that one entity
working alone could not achieve. The goal should be seen as a shared goal that all persons
or partners concerned should be seen to benefit from.
Everyone should gain

Appreciation of each others strengths

Building partnerships is based on recognizing the strength of each partner , accepting and
appreciating contributions made by each and making the most of each others contributions.
The strength of one will be recognized by the other

High pay off perceived from a long term relationship

Partner programs or organizations become proactively involved in partnerships if each of


them perceives some long term gain.
Partnership should generate a perception of high pay-off

Shared ownerships of outcomes (positive or negative)

Eventually, the program and its member partners need to develop by taking personal
responsibility for both successes and failures
In both success and failure , all partners will be responsible

Open and Frequent dialogue

Openness is required for exchanging feelings, receiving and giving ideas , feedback and
constructive criticism
There should be open and frequent dialogue among partners

Important Points to Remember

As a TB Program Manager , you should be aware of the strength of partnership and the
benefits that it can bring to program success
The concept of partnership mutuality (making sure that everyone benefits ) will help in
building strengthening and sustaining good partnership

MANAGING STAFF PERFORMACE


Management is about getting things done. As a TB program Manager you will be required
to deal with performance issues of staff from the general health system as well as key
RNTCP staff. You will have some staff who will be good performers, others who will perform
with more support and guidance while there will be some who do not perform even with
adequate support . As a program manager you will have to deal with performance issues in
a proactive, constructive and decisive manner.
What is Performance Management?
Performance Management is not a system or technique; it is the sum of the day-today
activities of all staff. It is also the systematic evaluation is employees job performance and
his/her potential for growth and development. It enables the TB program manager to not
240

Training Course for Program Manager


only identify performance gaps against set objectives but also helps the Program Manager
identify training and re-training gaps.
The following is an important framework for Performance management of staff in the
program

As a TB Program Manager you should:

Set objectives for your staff

Agree on the objectives jointly

Agree on measure of objectives

Agree on realistic time scale for achievement

Make them achievable yet challenging

Review Progress regularly.

Support and Guide through the year

Identify Performance Improvement Plan in case of performance deficiency


Take appropriate action for performance improvement and agree with the job holder
for the same.

FEEDBACK
Communication of information about an aspect of performance or behavior and its effects.
One of the key processes in managing performance of program staff is feedback. Many use
it as just a word in ordinary English language. In the context of managing staff performance
it is one of the most important and critical activities in the cycle of Performance
Management.
Giving feedback is as much an art as it is a science .Below are some of the key aspects of
feedback that will bring clarity to the whole concept and application of feedback that all
program managers must remember
Types of Feedback
Positive Feedback

Emphasize strengths
Mention areas of development
Be sincere

Benefits: Closer relationship


Increased motivation and mutual respect
241

Training Course for Program Manager


Negative Feedback

Sympathize and support


Do not blame or criticize
Stick to priorities
Sandwich positives and negatives
Always end on a positive note

Risks: De- motivation, loss of confidence


When do you give feedback?

Continuously as a part of the performance management cycle


Immediately after a positive or negative action
Praise in public , criticize in private
Pre- appraisal discussion
Points to remember

We should increase the personal effectiveness of our staff through appropriate feedback
and sharing.
Feedback should be a continuous process . there should be no surprises for the staff
member.

How to give Feedback


Some types of feedback serve only the needs of the person giving it and not the needs of
the person receiving it. This is likely to produce defensive reactions from the recipient and
they are unlikely to amend their behavior as a result, hence how you as a program manager
give feedback is equally important.

Feedback should be in terms of specifics and observable


Perceptions , reactions and opinions should be presented as such , not as facts
Feedback should refer to the relevant performance , behavior or outcomes , not to
the individual as a person
Feedback should be concerned with those areas over which an individual can
exercise some control and may include indicators of how the feedback can be used
for improvements or planning alternative actions.

In a nutshell:
Be specific

Describe what you see


Identify priority areas
Focus on Behaviors

Be constructive

Ask the job holder about his perspective


Transform problem areas into developmental opportunities
Find solutions together
Two- way process: Listen actively.
242

Training Course for Program Manager


Examples of Giving Effective Feedback
Motivational
I am impressed with the effective communications you have with the TB treatment volunteers.
You seem to have developed a trusting and open relationship with them over the past few
months
Developmental I have observed that some TB treatment volunteers forget to send the patients
for follow-up sputum examinations . It may be helpful to remind them to do so at your meetings
with them

How to receive feedback?


Feedback is always about past and therefore receiving feedback offers the possibility of
learning something valuable which may serve as a base for future development and
improvement.
The following steps can increase the value of feedback for the receiver:

Listen carefully
Ask questions to clarify disagreements or comments
Evaluate what is being said
Do not over-react to feedback, but you may wish to modify your behavior in
suggested directions and then evaluate the outcomes.

Managing poor performance


As a TB Program Manager, managing poor performance is one of the most critical
challenges that you will face. Here feedback is an important tool through which the process
of addressing poor performance issues, can be initiated. Some of the tips for managing
below average performance for TB Program managers are as under:

Deal informally with minor problems , through constant feedback , monitoring and
support
Arrange a meeting collate the facts and remain objective
Allow plenty of time for the individual to state their point of view
Options to deal with this problem for program managers
Set short term well defined objectives
Development interventions
Re-organize the job responsibilities
Agree corrective action and review periods
Keep a record / make note of discussions

Important points to remember:

Managing staff performance is not an annual activity , it is an on-going process.


Ignoring staff performance issues can have long term implications on the program
Appropriate interventions have to be made by the TB Program Manager to address performance
deficiencies
Feedback is an important tool to be used appropriately by program Managers on an on-going basis.
TB Program Managers should have the courage to say to say tough things to staff in relation to
performance, behavior and training.
It is important to be objective and evidence based when giving negative feedback

243

Training Course for Program Manager


Exercise:
As a TB program manager, if one of your staff members is not performing up to the
expected standards. Discuss your strategy to best handle this situation?
Conclusion
Finally, it is important to highlight that the overall goal of this training is to provide
participants with the necessary understanding and skills to develop and strengthen the
management of TB program in their area. The skills learnt through these modules could,
however, cut across functions and departments and can well be applied in the context of
other disease control or health projects as well.

244