One of the main bottlenecks of the Revised National Tuberculosis Control Programme (RNTCP) in district Shahdol is inadequate notification of the TB patientsi.e.123 against the target 197 per lakh. An operationally feasible action plan was prepared by the district TB Programme. The objective was to improve this through engaging all stakeholders involved in notification care pathway. At community level engaging community healers, private practitioners, timely disbursement of honorarium to DOT providers and removing language barriers were emphasized. Also, the capacity building of peripheral workers, timely grievance redressal and regular monitoring was plan focus in order to improve the TB notification.

Keywords: RNTCP Shahdol, TB notification, Action plan to improve TB notification, Tribal district

Shahdol district is located at the eastern part of Madhya Pradesh (MP), it has population of 1,066,063 with sex ratio 974 and literacy rate is 66.7%.¹ The population of Schedule Tribe and Schedule caste in district is 44.7% and 8.4% respectively.²The District Health System comprise of one district hospital at Shahdol, one civil hospital at Beohari akashranjan02@gmail.com, seven Community Health centres, 29 rural Primary Health Centres (PHC), one Urban PHC and 226 functional sub health centres. The district Revised National Tuberculosis Control Programme (RNTCP) has five TB units, 12 operational Designated Microscopic Centers (DMC). Overall, programme is thin staff in the district; it has one District TB Officer, two Senior TB laboratory supervisors (STLS), five senior treatment supervisors (STS) and two laboratory technicians (LT). The DMCs where the post of LT under the programme is vacant, the general LTs have been assigned additional RNTCP related lab work.

The challenges of RNTCP Shahdol Madhya Pradesh, is not very different from the other part of the country.^3-5 However, the tribal dominant population, trust of community on traditional healers, scarce and inaccessible public healthcare system, ineffective training of peripheral workers and poor grievance redressal related to honorarium disbursement related to DOT has rendered healthcare workers and treatment-supporters to overlook the RNTCP.^6-7 It has encouraged the treatment-supporters  (mostly ASHA workers) to engaged to Maternal and child health related services where honorarium disbursement is better ensured.⁸

One of the main bottlenecks of the programme in the district is inadequate notification of the TB patients. In the year 2018, the state notification rate was 172 against the state target 197 per lakh population. However, this notification rate is even low in district Shahdol i.e. 123 per lakh. Converting them in absolute numbers, it is approximately 1500 for the district. As per the set target for the year 2019 by the state, the Shahdol district has public and private notification target is 1800 and 500 respectively.

Action plan to improve TB notification: With the fast-changing dynamics of the programme since last few years, the sensitization and refresher training of healthcare workers are needed more than ever. The district RNTCP experience suggest, quality training is required almost at every level of healthcare worker involve in RNTCP i.e. Block Medical Officers, Medical officers, STS, STLS, TB LT, ASHA supervisors and ASHA workers.^6,7 On the basis of this, the following action plan was formulated to improve the TB notification rate in district Shahdol. (Figure 1).

Figure 1 Care pathway for TB management in district Shahdol.

The strengthening is required almost at every step of the care pathway of TB management in order to improve TB notification.

1. At community level: Shahdol being a tribal district where trust of the tribal community is more on Traditional healers, it’s high time to also engage them in the programme. Also, the ensured mechanism for timely disbursement of honorarium to DOT provider needs to be in place.
2. Engagement of private practitioners: Most of the patients registered to the programme have already visited at least 3-4 PPs before the diagnosis was made. So, engagement of PPSs through regular training, visit to their dispensary/hospital by programme staff, facilitating them in diagnosis and timely DBT can bring them in fold.
3. Capacity building of programme staff: As the guidelines of programme is changing very fast. Quality training and supportive supervision of healthcare staff will increase the TB notification rate in the district.
4. Registration of patients: Poor internet accessibility, slow Nikshay server in working hours, proforma in English language and not availability of information related to bank details of the patient delay the registration process of the patient. 

Activities already initiated as per the action plan: The care pathway for TB management, associated challenges and action plan to overcome those are illustrated in following Figure 1. However some of the activities under this action plan are already initiated, the list of those activities is as following:

1. One batch of ASHA (29 in number) all from Singapore are trained related to RNTCP in August 2018.
2. Training of two batches of ASHA facilitators from Burhar and Beohari block are already held on Oct 2018.
3. One batch each of STS and TB LTs, are trained at DTC.
4. Engagement meeting of Private practitioners of Shahdol was held on August 2018.
5. Mechanism of grievance redressal related to honorarium disbursement was streamline.
6. RNTCP Shahdol has developed a rater-based web form to track the home visits on real time basis.(9)
7. The handholding of RNTCP is being attempted during the field visits of STLS, DTO and faculty of GMC Shahdol.
8. The monthly review meeting is being held on priority basis on first Wednesday of every month under the leadership of CMHO on regular basis. The purpose of this meeting is not only to review the indicators but also acknowledge and try to overcome the perceive barriers of the RNTCP staff.

With this organized action plan, the district RNTCP is hopeful that, there will be increase of notification rate of TB patients under RNTCP Shahdol. Decentralized, district specific planning like this can be an effective strategy for implementing Global plan to End TB and National strategic plan 2017-25.

Micro plan based on above action-plan: Despite of the fact that RNTCP has already made accountable to the workers for every assigned job but lack of adequate HR at crucial positions, poor & ineffective training and lack of supervision on daily basis has been the biggest bottle neck for the RNTCP Shahdol. Based on, available staff, requirement and their capacity we developed a tailor made module for the district Shahdol and assigned job to every available RNTCP workers depending on his capacity and requirement. However, we suggest following activities has to be started and continue at earliest.

1. Arrange training of ASHA, ASHA shahyogini, ANM, MPW, TB LT, STS, PPs & MOs separately & as per need. Arrange meeting schedule in such a manner there has to be at least one training per month.
2. Set a grievance redressal system, for all TB related honorarium, preferably work for couple of hours in any one weekday e.g. 3PM to 5 PM every Friday or like that.
3. Strictly follow the TB module, (design and share by the RNTCP to every RNTCP worker) on daily basis, strict penalty if misses the schedule.
4. Daily reporting of TB cases from ward & visit to PPs (at least weekly basis). A worker must be identified and make accountable for it.
5. One supervisor must be identified at DTC level, who will supervise all the TUs/workers on daily basis (including their holidays/vacation/home visit/present location).
6. Name & contact no of above-mentioned supervisor has to be displaces at all DMCs/TUs/PHIs for any complaint/necessary action etc.
7. Seeking persistent help from the account section for all honorarium related matters. If any sort of delay happens to any payment (say for more than one month) e.g. DBT, private notification, PLO, TA etc. it has to be conveyed/explained to the concerned person rather than expecting him to come & ask regarding the same.
8. Good speed/uninterrupted internet connection must be ensured at every PHI/DMC/TU/DTC in an order to ensure timely and efficient data entry as per programme guidelines.

Nil.

The authors thank Revised National Tuberculosis Control Programme; district Shahdol, Madhya Pradesh for providing support and necessary guidance. We are also thankful to Dr. Rajesh Mishra (District TB Officer, Mr. Vikram Kalyani, Mr. Devendra Pratap Singh, Mr. Rupendra Singh Maravi, and Mr. Pushpendra Singh Dhurvefor their support. We also thank the Department for International Development (DFID), UK, for funding the Global Operational Research Fellowship Programme at the International Union against Tuberculosis and Lung Disease (The Union), Paris, France in which HDS works as a senior operational research fellows.

None.

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