| Test case
The Revised National Tuberculosis Programme envisaged expansion of the programme for microscopy centres. As of March 2001, of 563 MCs targeted only 281 (50 per cent) were participating in the programme...Shortfall of 282 MCs deprived 2.82 crore targeted population of the benefits of the scheme.
In 4 test-checked districts (except Darjeeling), there were 69 non-functioning MCs, thus depriving 0.69 crore people. In Malda there was a shortfall in MCs as the sites for setting up MCs were not identified...Reasons for the shortfall, for the state as a whole, were not stated by the additional director of health services (TB).
In one of the test-checked districts, action plans were prepared for implementation of either National Tuberculosis Control Programme or RNTCP. Requirement of anti-TB drugs under NTCP was never assessed. No advance planning was made for imparting training, identification of MCs, renovation thereof and for starting service delivery. Further, district-wise target for each component of work for the state as a whole was not prepared. As a result, the eligibility criteria for RNTCP were not fulfilled in time and the programme in the first phase started from the first quarter of 1999 in place of December 1997...In the second phase, only 6 out of 7 districts started functioning between August 2000 and April 2001...The programme did not start in the third year districts as of April 2001. Thus out of 18 districts where the programme was to operate in the state as of March 2000, only 12 districts were covered.
To detect maximum number of cases among patients attending outdoor departments of different government health institutions and to treat them effectively, NTCP was launched. Detection of TB was done through sputum examination and X-ray when the sputum is negative. Treatment is rendered under two regimens namely, standard (for both sputum positive and negative cases) and short course regimen (for sputum positive cases only). (a) Shortfall in sputum examination and identification of smear positive cases: during 1996-2001 in the state, shortfall in targeted sputum examination increased from 52 to 84 per cent and in identification of new smear positive cases from 39 per cent to 64 per cent...Due to such steep increase in shortfall of examinations, sputum positive cases increased from 13 per cent to 23 per cent over the estimated rate of 10 per cent. Thus the disease was spreading. No steps were taken to achieve the target as fixed by the government of India. Possibility of a good number of suspected sputum positive cases remaining undetected also could not be ruled out.
In the 4 test-checked districts (Bardhaman, Birbhum, Darjeeling and Malda), shortfall in sputum examination and identification of new smear positive cases averaged 55 per cent and 4 per cent respectively during 1996-2001...
(b) Unfruitful expenditure on dropouts in the state, 2.72 lakh patients (22 per cent) left ...before completion of treatment thus increasing the scope of spreading the disease and rendering the expenditure of Rs 8.02 crore on their treatment unfruitful.
The statewide position of treatment and drop-outs was as follows: in the 4 test-checked districts...0.31 lakh out of 3.47 lakh patients completed full course of treatment and 0.50 lakh patients (14 per cent) received partial treatment. Expenditure of Rs 1.39 crore on incomplete cases had become unfruitful. The drop-outs were attributed to the irregular supply of ATDs by the implementing authorities of the units. It was, however, observed that lack of home visits by health staff, motivation among patients and absence of health education, inadequate monitoring and supervision were the other factors contributing to such large drop-outs.
Due to large number of drop-out cases, expenditure of Rs 9.02 crore for the state became largely wasteful. Further the possibility of the patients becoming drug-resistant could not be ruled out due to inadequate drug intake or discontinuation of treatment.
(c) Inadequate diagnostic centres: in the 3 test checked districts (Bardhaman, Birbhum and Malda), only 11 diagnostic centres were functioning as against at least 79 due to be available under NTCP. Further 68 block primary health centres out of a total of 70 centres had no such facility due to failure of the assistant chief medical officer of health (public health and family welfare) to supply reagents, which cost only Rs 7 per patient. No target was fixed by the ACMOHs (PH & FW) for sputum examination though laboratory and technicians were available. Thus patients were deprived of getting their sputum examined from a nearby centre while the staff and laboratory were not utilized.
(d) Treatment without conducting tests (i) in 4 test-checked districts (Bardhaman, Birbhum, Darjeeling and Malda), 0.84 lakh patients were registered during 1996-2001...In Darjeeling district, 16,507 patients were put under treatment against 18,680 detected leaving 2,173 patients. In Malda district 11,223 patients were given treatment (total detection being 11,291 and number put on treatment — 22,514). All these treatments were given without conducting sputum examination.