INT J TUBERC LUNG DIS 7(9):837–841
© 2003 IUATLD
Impact of national consultants on successful expansion
of effective tuberculosis control in India
T. R. Frieden,*†‡ G. R. Khatri§¶
* Regional Office for Southeast Asia, World Health Organization, New Delhi, New Delhi, India; † NYC Department of
Health and Mental Hygiene, New York, New York, ‡ National Center for HIV, STD, and TB Prevention, Centers for Disease
Control and Prevention, Atlanta, Georgia, USA; § Directorate General of Health Services, Ministry of Health and Family
Welfare, Government of India, New Delhi, India; ¶ FIDELIS, International Union Against Tuberculosis and Lung Disease
(IUATLD), Paris, France
SUMMARY
S E T T I N G : India, during a period of rapid expansion of
DOTS services. DOTS expansion has been slow in many
countries.
O B J E C T I V E : To document use of consultants to expand
DOTS effectively.
D E S I G N : Staff were contracted to monitor DOTS
expansion and implementation. To estimate the impact
of these staff, we compared areas with and without consultants, and individual areas before and after consultants
were assigned. Consultants were preferentially assigned
to the more difficult areas; the temporary absence of consultants reflected non-availability of candidates.
R E S U L T S : Areas with consultants met pre-defined criteria and began DOTS service delivery faster (median 9 vs.
18 months of preparation) than areas without consul-
tants. Rates of sputum conversion (87% vs. 83%, P 0.001) and treatment success (83% vs. 78%, P 0.001) were significantly higher in areas with consultants present.
C O N C L U S I O N : Assignment of consultants resulted in
much more rapid implementation of the DOTS strategy,
and better quality performance. Continued effective performance in these areas will rely on many factors, but
the need for consultants appears to be decreasing, suggesting that they have provided sustainable improvements. The effectiveness of local consultants may have
important implications for efforts to scale up public
health interventions for tuberculosis, malaria, AIDS and
other diseases in developing countries.
K E Y W O R D S : tuberculosis; DOTS; WHO; supervision
THE DOTS (directly observed treatment, short-course)
strategy has been the World Health Organization
(WHO) recommended strategy for tuberculosis control since 1994.1 However, by 1999 less than one out
of four patients in the world were being treated under
this strategy.2 In India, progress in expansion of DOTS,
known as the Revised National Tuberculosis Control
Programme (RNTCP), was slow from 1993–1998,
then rapid from late 1998 to the present.3,4 Many factors have contributed to the rapid and successful
expansion of DOTS in India.5 One important factor
has been the use of WHO-contracted local consultants.
This article reviews the methods by which these staff
were recruited, trained and supervised, and provides
minimum estimates of their effectiveness and impact
based on an ecological correlation between the presence
of consultants and the pace and quality of expansion.
among patients self-reporting to health services, regular supply of anti-tuberculosis drugs, standardized
short-course treatment given by directly observed
treatment, and systematic monitoring and accountability for treatment results.1 In India, the RNTCP is
implemented by districts (average population, 2 million), with central and state government support.
Prior to initiation of service delivery, districts must
meet pre-defined appraisal criteria including the hiring of a small number of local staff to help run the
programme and training of large numbers of health
workers. After the beginning of service delivery, each
district submits quarterly reports on case detection,
patient progress (conversion of sputum smears for
acid-fast bacilli from positive to negative), outcomes
of every patient started on treatment, and programme
management. The programme is funded by the central and state governments of India, the World Bank,
and bilateral donors. WHO-contracted staff have
been funded by the WHO and the Canadian International Development Agency.
From August 1999, WHO-contracted staff, known
METHODS
The DOTS strategy consists of political commitment,
case detection using smear microscopy primarily
Correspondence to: Dr Thomas R Frieden, Commissioner, Department of Health and Mental Hygiene, 125 Worth Street,
CN28, Room 331, New York, NY 10013, USA. Tel: (1) 212-295-5427 or 295-5341. Fax: (1) 212-295-5426. e-mail:
[email protected]
Article submitted 5 September 2002. Final version accepted 18 March 2003.
[A version in French of this article is available from the Editorial Office in Paris and from the IUATLD Website www.iuatld.org]
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The International Journal of Tuberculosis and Lung Disease
as RNTCP Medical Consultants (RMCs), were assigned to assist the State and district governments in
supervision of the programme. RMCs are required to
have a medical degree and at least 2 years of experience. The positions are advertised in national newspapers, and short-listing is by a professional firm.
Between 1% and 5% of applicants were offered positions, more than 80% of those offered positions
accepted, and retention has been more than 90%.
Selection is by a joint committee of WHO, the Government of India, and a State government. Consultants are trained for 2–3 weeks initially, including
technical, administrative and operational aspects of
the RNTCP, use of computers, data analysis, writing,
presentation skills and 5 days of field supervision
with an experienced supervisor. RMCs are generally
provided with a jeep and laptop computer, and are
reimbursed for work-related cell phone and internet
use. A per diem for overnight visits is provided. Salaries are equivalent to government compensation for
doctors with a similar level of responsibility. RMCs
report to State and Central governments of India and
to WHO on a monthly basis, and are provided with
technical supervision and advice from WHO. Approximately twice a year there are meetings of all RMCs;
WHO staff visit RMCs once or twice a year for
hands-on training and supervision.
Consultants are charged with the following duties:
to provide technical support and assistance for training, supervision, implementation, monitoring and
appraisal of the RNTCP according to Central governmental policy; investigate cases of treatment failure,
default, death and relapse to determine causes and
implications for programme improvement; visit all
tuberculosis units and other peripheral institutions
within assigned districts on a regular schedule, identifying problems in logistics and proposing solutions;
assist in coordination among governmental and nongovernmental organizations and private physicians;
and communicate information on programme and
policy implementation, including programme status
and financial reporting.
The policy was to provide one consultant to oversee RNTCP preparation or implementation for districts with a total population of approximately 10
million. However, due to a scarcity of suitable candidates, the failure of several applicants to begin work
as scheduled, delays, and unexpected departures,
some areas were without RMC coverage for one or
more quarters. Areas without RMC coverage were
generally those expected to be better-performing; available consultants were preferentially sent to the more difficult areas (i.e., those areas with lower socio-economic
development, weaker state tuberculosis control programmes, and/or weaker health systems).
To estimate the effectiveness of consultants, areas
with and without RMC coverage were compared. We
analysed data from all 160 implementing districts over
10 quarters, representing an evaluation of more than
200 000 patients from the beginning of 1999 to mid2001. Areas whose implementation was supported by
bilateral donors (5% of total implementing districts
during this period), which utilised different supervisory mechanisms, were excluded from analysis.
Four separate impact indicators were assessed: pace
of expansion, sputum conversion rate, cure rate and
treatment success rate. Pace of expansion was defined
as the number of months between approval and start
of DOTS provision. DOTS can only begin in India
after predetermined appraisal criteria relating to hiring and training of staff have been met. Cure and
treatment success rates were defined as per WHO
guidelines.6
To estimate the impact of consultants, average case
detection and cure rates were compared based on
published and locally available data, as follows: total
case detection rate under DOTS: 126 per 100 000
population;4 cure rate under DOTS of 82% and less
than 40% under non-DOTS treatment;2 case fatality
rate in smear-positive patients treated under DOTS:
5%;2 case fatality rate in smear-positive patients
treated under non-DOTS: 29%;7 overall difference in
case fatality rate between DOTS and non-DOTS (all
patients): 18%.*
RESULTS
In the 2.5 years of data analysed, consultants were
provided for 74% of the population covered, leaving
26% of the population without consultants. Prior to
consultants being in place, it took a median of 18
months to begin service delivery in a small number of
districts. A much larger number of districts have
taken a median of 9 months to start service delivery
since consultants have been in place. A similar difference has been seen in districts with and without consultants present during the preparatory phase.
Sputum conversion, cure and treatment success
rates are significantly higher in districts with RMCs in
place (Figure 1). Rates of sputum conversion, reflecting effective treatment, were higher in areas with
local supervisors (87% vs. 83%, P 0.001). Similarly,
the treatment success rate was higher in areas with
local supervisors: (83% vs. 78%, P 0.001). These
differences were quite consistent over time, as shown
for the success rates in Figure 2. Another way to evaluate effectiveness is against minimum performance
standards: 79% of districts covered by an RMC had
success rates 80%, compared with only 53% of districts without a consultant; sputum conversion was
80% in 87% of districts with a consultant compared
with 72% of districts with no RMC (P 0.001 for
both comparisons).
* See www.tbcindia.org/method.asp for details of calculation.
Impact of national consultants on TB control in India
839
Figure 1 Sputum smear conversion, cure and success rates in districts with and without medical
consultants, Revised National Tuberculosis Control Programme, India, August 1999–June 2001.
Based on these data it is possible to estimate the
public health impact of RMCs. By expediting service
delivery by 9 months, the average RMC, covering a
population of 10 million, resulted in treatment of an
additional 10 000 patients under the DOTS strategy,
of whom at least 4000 would not otherwise have
been cured (9/12ths of a year 126 cases/100 000 10 million population; cure rate 82% vs. 40%), and
averted nearly 2000 deaths among these patients. By
increasing the treatment success rate in areas under
DOTS implementation, each RMC resulted in 1000
additional patients being successfully treated (126
cases/100 000 0.08% increase in treatment success) in each year of programme implementation.
Figure 2 Treatment success rates in districts with and without
medical consultants, Revised National Tuberculosis Control Programme, India, August 1999–June 2001.
DISCUSSION
Contracting of consultants by WHO in conjunction
with the Government of India and state governments
appears to have resulted in much more rapid implementation of the DOTS strategy and better quality of
performance. The total annual cost of each consultant, including salary, benefits, travel, equipment and
administration, has been less than $20 000 per year
(WHO, unpublished data). This is in addition to the
costs of implementation of DOTS (drugs, microscopy,
training, local staff, etc.). In the first year of DOTS
implementation, a group of less than two dozen consultants each resulted in an average of 4000 additional
patients cured and 2000 deaths averted.
Consultant impact is much greater in the first year
of implementation than in subsequent years. This is
because DOTS implementation results in a dramatic
improvement in performance; expediting this implementation has substantial benefits. In subsequent
years, consultants significantly improve performance,
but from an already high level. Hence, from both programmatic and cost-effectiveness perspectives, use of
RMCs in the early stages of expansion and implementation is of greatest importance.
The relative merits of vertical versus horizontal
implementation of public health programmes have
long been debated.8,9 Consultants in the tuberculosis
control programme were hired in an analogous fashion to consultants hired earlier for the polio eradication programme.10,11 Consultants have been used in
various public health programmes, but there is a surprising lack of description and analysis of the methods used and of the results of assignment of national
consultants in the medical and public health literature.
The DOTS programme in India is implemented by the
general health staff in rural areas and specialised staff
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The International Journal of Tuberculosis and Lung Disease
in some urban areas. In urban areas, high caseloads
make the use of specialised staff more efficient. In
addition to the consultants described in this article,
for each 1 million population covered, two full-time
treatment supervisors and two full-time laboratory
supervisors are provided.
Treatment and laboratory supervisors in the health
system are a critical first line of supervision. Consultants contracted by WHO were able to strengthen state
and district tuberculosis control officers’ ability to
implement the programme, largely by increasing the
effectiveness of the health system’s treatment and laboratory performance and supervision. The existence of
specialised, full-time supervisory staff both within and
outside the regular health care delivery system has been
essential. We believe this type of specialised supervision is likely to be essential for successful implementation of many public health programmes in developing
countries. Some of the most important functions of the
consultants have been to ensure ongoing progress with
preparation for service delivery, ensure accurate and
timely reporting, and address problems or poor performance in specific geographic areas as they arise.
The estimates presented here are likely to be robust
for several reasons. First, they are consistent among
indicators. Cure rates, success rates and sputum conversion rates all vary at around the same rate. Second,
the analysis is consistent for results analysed crosssectionally—comparing all districts in each quarter
with and without consultants—as well as longitudinally, comparing districts that lacked consultants for
the quarters in which they were with and without a
consultant. Third, these represent conservative estimates, as districts lacking a consultant sometimes did
have partial services of a consultant from a neighbouring district. Fourth, we have included as ‘consultant’
quarters even those rare cases in which a poorly performing consultant was posted; this would tend to
make the results under-estimate the actual impact. It
is unlikely that the superior performance of districts
with consultants is due to the characteristics of the
districts themselves, because consultants were preferentially assigned to districts that were considered more
likely to have difficulties in effectively implementing
the RNTCP (e.g., because these areas had lower socioeconomic status, no full-time state tuberculosis control
officer, or a relatively weak health system).
There are important limitations to this analysis.
Many variables affect performance, relatively few
areas have been without a consultant for significant
periods of time, some poorly performing districts did
not report accurately (particularly when no RMC
was present), performance may take 2–3 quarters to
improve after an RMC was posted, the presence of an
RMC earlier can make a difference much later, and if
an RMC joins later, she or he can sometimes significantly improve performance from periods when there
was no consultant. All of these limitations would tend
to reduce the measured impact of RMCs, hence the
differences documented in this study are most likely a
minimal estimate of the impact of supervisors on performance. There is also a possibility of unrecognised
selection and information bias.
A further limitation of this analysis is that RMC
effectiveness relies on a large range of input, including
technical and logistic support from the Government
of India, World Bank funds, State and District government staff, etc. However, RMCs provide a critical
leverage input to make all of these resources more
effective in programme implementation.
Continued effective performance in these areas
will rely on many factors, but the need for local consultants appears to be decreasing, suggesting that
these staff provide sustainable improvements. Consultants focus on establishing patterns of effective
functioning; these patterns are much easier to sustain
than they are to establish. The plan is to provide consultants for 3–4 years after full implementation of
DOTS, then to reduce the number to no more than
one per state in most areas.
The effectiveness of local consultants may have
important implications for efforts to scale up public
health interventions for tuberculosis, malaria, AIDS
and other diseases in developing countries.
Acknowledgements
We thank the RNTCP Medical Consultants for their hard work
and dedication to tuberculosis control in India, the Canadian International Development Agency for financial support of this project,
Mr Santhosh Kumar for expert assistance with data management
and manuscript preparation, and Mr Drew Blakeman for assistance with manuscript preparation.
References
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4 Ministry of Health and Family Welfare. TB India 2001: RNTCP
status report. New Delhi: Government of India, 2001, 44 pp.
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lessons for the world. Bull World Health Organ 2002;80:457–463.
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10 Banerjee K, Hlady W G, Andrus J K, Sarkar S, Fitzsimmons J,
Abeykoon P. Poliomyelitis surveillance: the model used in India for
polio eradication. Bull World Health Organ 2000; 78: 321–329.
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Impact of national consultants on TB control in India
841
RÉSUMÉ
L’Inde, au cours du développement rapide
des services de DOTS. Le développement du DOTS s’est
avéré lent dans beaucoup de pays.
O B J E C T I F : Documenter les méthodes utilisées pour le
développement du DOTS de façon efficiente.
S C H É M A : Des consultants ont été engagés pour superviser le développement et la mise en œuvre du DOTS. Pour
estimer l’impact de ces superviseurs, nous avons comparé
les zones avec ou sans superviseurs ainsi que des zones
individuelles avant et après la désignation des superviseurs. Les consultants ont été désignés de façon préférentielle dans les zones les plus difficiles : l’absence temporaire de consultants a résulté de l’absence de candidats.
R É S U L T A T S : Les zones où des consultants avaient été
désignés ont été capables de répondre aux critères prédéfinis et de commencer la fourniture de services DOTS plus
CONTEXTE :
rapidement (une préparation médiane de 9 mois vs. 18
mois) que les zones sans superviseurs. Les taux de négativation des expectorations (87% vs. 83%, P 0,001) et
du succès du traitement (83% vs 78%), P 0,001) ont
été plus élevés dans les zones avec consultants.
C O N C L U S I O N : La désignation de consultants a entraîné
une mise en œuvre beaucoup plus rapide de la stratégie
DOTS et une meilleure qualité des performances. La
poursuite d’une performance efficiente dans ces zones
dépendra de nombreux facteurs, mais le besoin de consultants semble décroissant, ce qui suggère qu’ils ont fourni
des améliorations de longue haleine. L’efficience des consultants locaux pourra avoir des implications importantes
pour les efforts visant à améliorer les interventions de santé
publique en matière de tuberculose, malaria, SIDA et
autres maladies dans les pays en développement.
RESUMEN
C O N T E X T O : La India, durante el desarrollo rápido de
los servicios de DOTS. La expansión del DOTS ha sido
lenta en muchos países.
O B J E T I V O : Documentar los métodos utilizados para la
expansión del DOTS de manera eficaz.
D I S E Ñ O : Consultantes fueron contratados para supervisar la expansión y la implementación del DOTS. Para
estimar el impacto de estos supervisores se compararon
áreas con y sin consultantes asignados, así como áreas
individuales antes y después de la designación de supervisores. Los consultores fueron asignados preferentemente
a las áreas más difíciles ; la ausencia temporal de consultores resultaba en una indisponibilidad de candidatos.
R E S U L T A D O S : Las áreas con consultores asignados
fueron capaces de lograr los criterios predefinidos y de
comenzar a prestar servicios más rapidamente (una
mediana de 9 meses de preparación contra 18 meses),
que las áreas sin supervisores. Las tasas de negativización de la expectoración (87% contra 83%, P 0,001)
y de éxito del tratamiento (83% contra 78%, P 0,001)
fue más elevada en las áreas con consultores.
C O N C L U S I Ó N : La designación de consultores tuvo
como resultado una implementación mucho más rápida
de la estrategia DOTS y un rendimiento de mejor calidad. La continuidad de un rendimiento eficaz en estas
áreas dependerá de muchos factores, pero la necesidad
de consultores parece disminuir, lo que sugiere que estos
consultores han aportado mejoramientos durables. La
eficacia de los consultores locales puede tener implicaciones importantes para los esfuerzos dirigidos a perfeccionar las intervenciones en tuberculosis, malaria, SIDA
y otras enfermedades, en los países en desarrollo.