STS: Supervision, Monitoring and Evaluation

Concept of Supervision

• Supervision is a systematic, ongoing process for increasing the efficiency of health personnel by developing their knowledge, perfecting their skills, improving their attitudes towards their work and increasing their motivation.
• It is one of the most important management functions in an organisation.
• Supervision is also defined as an act of a superior person overseeing the work of the personnel working under him or her. This overseeing means directing, investigating, guiding, helping and advising the subordinates in their performance with the purpose of achieving the established objectives.
• Therefore, it is an extension of training which provides constant observation, monitoring, evaluation and guidance to workers, with the aim of enabling them to perform their activities effectively and efficiently while maintaining the required standards.

 

Basic Tenets of a Good Supportive Supervisory Process

• Supervision is carried out in direct contact with health personnel.
• It is a two-way communication between supervisors and those being supervised.
• Supervisors are always accountable for the performance of the subordinates under her/his span of control.
• It should not be a fault-finding exercise but a collaborative effort to identify problems and find solutions. Supervisors are to help the workers improve, develop and reinforce knowledge and skills according to their individual learning needs.
• Supportive supervision is provided to health personnel at all levels since they need ongoing support for solving problems and to overcome difficulties.
• Health personnel also need constructive feedback on their performance and continuous encouragement in their work.
• Supportive supervision assists workers to perform in the best possible way to yield the best results in terms of realisation of the organisational goals.

Supportive supervision ensures smooth implementation and continuous programme improvement.

 

Objectives of Supervision

• To ensure equitable provision of high-quality healthcare services to all sections of society.
• To build capacity of the health staff to implement programme procedures correctly.
• To increase the involvement and commitment of staff at different levels, and to help staff develop their highest potential.
• To plan services cooperatively and to develop coordination to avoid overlapping.
• To develop standards of service and methods of evaluation of personnel and services.
• To assist in problem-solving of the matters concerning personnel, administrative and operational services.
• To provide timely and actionable feedback.
• To assess human resources and their training needs.
• To ensure logistic management as per guidelines.
• To ensure accurate and valid data recording and reporting in Nikshay and other recording systems.
• To interpret policies, objectives and needs of the organisation and to suggest ways and means to improve them.

 

Resources

• NTEP Training Modules (5-9) for Programme Managers & Medical Officers, 2020.
• Supervision and Monitoring Strategy, RNTCP, 2012.

 

Assessment

 

Question​	Answer 1​	Answer 2​	Answer 3​	Answer 4​	Correct answer​	Correct explanation​	Page id​	Part of Pre-test​	Part of Post-test​
Which of the following are the basic principles of supervision?	It is an ongoing process.	It involves a co-ownership between supervisors and those supervised.	It is a fault-finding exercise designed to point out the weaknesses in healthcare personnel.	Options 1 and 2	4	Supervision is an ongoing, two-way communication between supervisors and those being supervised. It should not be a fault-finding exercise but a collaborative effort to identify problems and find solutions.	​	Yes	yes

 

 

The Senior Treatment Supervisor (STS) is a part of the Tuberculosis Unit (TU) team at the sub-district level in the National TB Elimination Programme (NTEP).

The STS is responsible for supervising the treatment of the patients and works closely with treatment supporters and Primary Health Care system.

The objective of these supervisory visits is to supervise patients' treatment and to monitor the programme at the TU level. They also support the treatment supporters to carry out their role efficiently and troubleshoot the issue that they might face.

The visits by STS are conducted on a systematic basis and the protocol to be followed during these visits is shown in the figure below.

 

Figure: Supervisory Protocols for the STS

 

Supervisory Checklist for the STS

A supervisory checklists can be used by the STS to make sure that s/he does not miss any aspect during the visit. In summary, the STS must supervise the following:

1. Facility assessment:

• Anti-TB drugs: Assess for storage conditions (including if First-Expired, First-Out (FEFO) is followed), stock availability and stock-outs.
• Infrastructure: Presence and condition of physical spaces (including cleanliness) for patient consultation and waiting areas, availability of functional X-ray units (in case of X-ray centres) and weighing scales.
• Supplies: Assess the quantity of supplies such as sputum containers, forms, and treatment cards.

2. Case detection and diagnosis: Check if all suspects identified were referred for diagnosis, check referral in Nikshay and specimen processed, check for any losses, check if all specimen collected reached laboratory and examined. Check if all diagnosed are tacked correctly.

 

3. Treatment: This includes monitoring for:

• Early treatment initiation, entry in Nikshay (Notification), and allocation of treatment supporter. 
• Appropriate medicine dosage by weight and type.
• Alternative resources mobilised for treatment observation.
• DOT for every dose in the Intensive Phase (IP) of treatment.
• Universal Drug Susceptibility Testing  
• Prompt follow up sputum examinations 
• Acceptability of the treatment supporter to the patient
• Prompt treatment tectorial efforts for interrupting patients

 

4. Recording and Reporting: This includes:

• Ensuring all patients are correctly registered in Nikshay 
• Proper updation of treatment schedules and doses, including retrival actions in Nikshay by the treatment supporter
• All treatment supporters are given Nikshay credentials, their Direct Benefit Transfer (DBT) entered in the Nikshay properly
• DBT of the patients correctly recorded in the nikshay portal
• DBT of the private providers are recorded correctly in the Nikshay portal

 

     5. Patient interviews: The STS should check the following:

• TB knowledge: If the patient knows about TB, its symptoms, drugs prescribed, duration of treatment, consequences of irregular/ incomplete treatment, frequency and importance of follow up tests, and importance of examining symptomatic close contacts.
• Monitoring: If they are receiving DOTS as prescribed, if the Peripheral Health Worker (PHW) knows their home, frequency of home visits during IP/ Continuation Phase (CP)/ missed doses, and if help from family members/ others was ever enlisted.

     6. Supportive supervision with on job capacity building:

• The STS is expected to build the capacity of treatment supporter during the field visit. Build their capacity by 
  • Demonstrating Nikshay portal entry 
  • Imparting skills on the patient support system (guiding, counselling, contact tracing, treatment retrieval, Adverse Drug Reaction management, DBT and other social schemes etc)

 

Resources

• Module for Senior Treatment Supervisors, RNTCP, 2005.
• Training Modules (1-4) for Programme Managers and Medical Officers, 2020.

 

Assessment

Question​	Answer 1​	Answer 2​	Answer 3​	Answer 4​	Correct answer​	Correct explanation​	Page id​	Part of Pre-test​	Part of Post-test​
How often should an STS visit a PHI in their area?	Once a month	Twice a month	Every quarter	Every day	3	Senior Treatment Supervisors (STS) should cover all PHIs/ treatment observation centres every quarter.		Yes	Yes
The STS can involve themselves in role plays to communicate key health messages.	TRUE	FALSE			1	Senior treatment supervisors can involve themselves in role plays with MPWs/ DOTS providers to communicate key health messages.		Yes	Yes

 

At a DMC, the STS primarily ensures that 

1. All patient services from enrolment to outcomes for a TB patient are completed optimally. This is done by monitoring information submitted by the DMC such as referral for testing, no of people tested, no of people diagnosed with TB, initiated on treatment. 

2. All the patients started on treatment are tested promptly using the appropriate follow-up testing schedule( i.e. at the end of IP and CP). 

3. Maintain profile of the DMC in the Nikshay such as tagging the PHI as DMC, name of contact person and other particulars

4. Ensure data quality in the various records, both in physical and electronic records. This includes patient data, referral data and testing data.

At the Tuberculosis Unit (TU), the presiding supervisory team uses a standardized checklist mandated by the National TB Elimination Programme (NTEP) during their periodic supervisory visits. The report and copies of the checklist may be shared with appropriate authorities within 1 week of completing the supervisory visit.

These appropriate authorities include the Central TB Division, Ministry of Health and Family Welfare (MoHFW) and respective district and state authorities, who will in turn initiate remedial measures in a timely and appropriate manner.

The TB Unit/ Designated Microscopy Centre (DMC)/ Peripheral Health Institute (PHI) Health Facility Checklist is shown in the table below.

Table: Checklist for Supportive Supervisory and Monitoring Visits under NTEP for TB Unit/ DMC/ PHI - Health Facilities

Name of the TB Unit/ DMC/ PHI: Name of District and State: Date of Visit: Facilities Visited:
1	Interact with the Medical Officer (MO) to know their involvement in TB case detection. Look at the Outpatient Department (OPD) register to know what % of adult OPD patients are being referred for sputum microscopy.	%
2	% of MOs trained in NTEP on the management of TB cases. (Assess their knowledge on NTEP, Cartridge-based Nucleic Acid Amplification Test (CBNAAT)/ Truenat services, newer Drug-resistant TB (DR-TB) drug regimen, Nikshay Poshan Yojana, etc.)	%
3	Is the MO regularly undertaking supervisory visits? (Observe the field visits undertaken by the MOs in the supervisory register)	Y/N
4	Information, Education and Communication (IEC)/ Advocacy, Communication and Social Mobilisation (ACSM) activities undertaken by the MO? (Enquire about the ACSM activities like school health programs, village health sanitation and nutrition meetings, community orientation meetings etc. undertaken, and observe for visible IEC wallpapers/ banners etc. in the PHI and its vicinity)	Adequate/ Not adequate
Designated Microscopy Centres
5	Are the sputum samples being tested as soon as they are received? (Observe for the presence of Laboratory Technician (LT) availability on all days, availability of Binocular/ Fluorescence Microscope(BM/ FM), the average time taken from the time of sample receipt to smear result reported (lab turnaround time)	Y/N
6	Is the LT trained in performing smear microscopy? (Assess their knowledge of the smear microscopy procedure)	Y/N
7	Lab turnaround time - Average time taken from the time of sample receipt to smear result reported	(in days)
8	Are chest symptomatics offered chest X-ray? (either directly or linked with an X-ray centre - % of chest symptomatic offered)	Y/N
9	Is there provision for collection and transport of samples of key populations/ TB notified patients to the CBNAAT/ Truenat lab available? (Review the transport mechanism available)	Y/N
10	Are presumptive TB patients offered HIV testing? (% offered HIV testing – Check in the Lab register)	Y/N
11	Are there adequate supplies of reagents, slides and other consumables for the next month? (Check for the reagents availability, quantity and labelling of expiry date)	Y/N
12	Does the DMC have continuous water and electricity supply?	Y/N
Treatment Services
13	Are all diagnosed patients notified in the TB notification register? (Cross check the lab register with the TB notification register and look for the Nikshay id)	Y/N
14	Are all notified patients initiated on treatment? (Including those referred/ transferred out)	Y/N
15	Average time taken for treatment initiation from the time of diagnosis? (Calculate for 30 recent patients including those transferred/ referred out)	(in days)
16	Are TB-notified patients offered HIV testing? (% offered HIV testing – Check in the TB notification register/ Nikshay)	Y/N
17	Are TB-notified patients offered Diabetes Mellitus (DM) testing? (% offered DM testing – Check in the TB notification register/ Nikshay)	Y/N
18	Are TB notified patients screened for Tobacco usage? (% screened for tobacco usage – Check in the TB notification register/ Nikshay)	Y/N
19	Nikshay Poshan Yojana - % of TB notified patients who have been offered Nikshay Poshan Yojana (Patients currently in the PHI for the last 1 year may be taken)	%
Treatment Supporters
20	Does the treatment supporter require training/ sensitisation? (Assess knowledge in Directly Observed Therapy Short-course (DOTS), treatment card maintenance, patient services, Nikshay Poshan Yojana)	Y/N
21	Is the treatment supporter monitoring daily drug intake by the patient (either directly/ digital adherence)? (Check the treatment card – cross-match with drugs issued and pills taken)	Y/N
22	% of honorarium received? (Ask whether the treatment supporter has received the honorarium for all eligible patients who have completed their treatment)	%
Field Supervisors (Senior Treatment Supervisor (STS)/ TB Health Visitor (TBHV)/ General Health System (GHS) Staff)
23	Is an individual vehicle available for field visits?	Y/N
24	% of TB notified patients currently on treatment in whom home visits have been undertaken? (Cross check with the treatment card/ Lat. long. coordinates captured in Nikshay/ patient interaction)	%
25	% of TB notified patients currently on treatment linked to a treatment supporter?	%
26	% of children identified in whom chemoprophylaxis with Isoniazid has been given?	%
27	Has the staff received the salary & POL to date? If No, record the issues therein?	Y/N
28	% of private notified patients in whom public health actions have been provided?	%
Senior TB Lab Supervisors (STLS)/ GHS staff
29	Is the STLS reviewing slides preserved by the LT during the On-site Evaluation (OSE)?	Y/N
30	Are the reports of TU-OSE done by the STLS available in the DMC? (Check for the copy of at least the last month)	Y/N
31	Is corrective action as suggested in the TU-OSE report being carried out by the DMC? (Current status may be used as an assessment of the corrective actions taken)	Y/N
32	Assess 2 slides to check if they match with the OSE report?	Matches/ Does Not match
Drug Store
33	Is the stock register maintained as per guidelines?	Y/N
34	Are the drug stocks adequate as per the suggested norms?	Adequate/ inadequate
35	Are the stocks matching with Nikshay Aushadhi?	Y/N
36	Is bio-medical waste from the DMC disposed of as per Bio-Medical Waste (management and handling) Rules 2016
Comments and Recommendations: (Use an extra sheet, if required)
1
2
3
4
Name and signature of the visiting team members with their designation:

 

Resources

• NTEP Training Modules (5-9) for Programme Managers & Medical Officers, 2020.
• Supervision and Monitoring Strategy, RNTCP, 2012.

 

Assessment

 

Question​	Answer 1​	Answer 2​	Answer 3​	Answer 4​	Correct answer​	Correct explanation​	Page id​	Part of Pre-test​	Part of Post-test​
The TB Unit/ Designated Microscopy Centre (DMC)/ Peripheral Health Institute (PHI) Health Facility Checklist covers which of the following thematic areas?	Advocacy, Communication and Social Mobilisation	Direct Benefit Transfer	Stock availability	All of the above	4	The TU level checklist covers ACSM, DBT and stock availability as well as other parameters at the TU level.	​	Yes	Yes

 

 

 

The Medical Officer-TB Control (MO-TC) at the TB Unit (TU) has the overall responsibility for the management of the National TB Elimination Programme (NTEP) at the sub-district level and is assisted by the Senior Treatment Supervisor (STS) and the Senior TB Lab Supervisor (STLS).

The MO-TC is responsible for supervising the work of the TU and of the STS and STLS, in addition to his/her other responsibilities. These visits are conducted on a systematic basis and the protocol to be followed during these visits is shown in the figure below.

Figure: Supervisory Protocols for the MO-TC 

Abbr: NGO: Non-government Organisation

 

Checklist for the MO-TC at the TU

 

• Ensure that all private-sector patients are captured in the Nikshay portal by notification and that public health actions are taken on all TB patients notified irrespective of private or public.
• Ensure that the treatment supporters are adequately trained and updated on the latest guidelines. 
• Ensure that the treatment supporters and the private providers are allotted proper Nikshay credentials and that the troubleshooting mechanism works promptly.
• Organise sputum smear examination at all DMCs of the sub-district.
• Ensure proper treatment categorisation of diagnosed patients by supporting other MOs of the sub-district. 
• Ensure that Directly Observed Treatment (DOT) is taking place as per guidelines at all treatment observation centres.
• Ensure a regular supply of drugs and other logistics and ensure their uninterrupted availability in all Peripheral Health Institutes (PHIs) in the sub-district.
• Ensure periodic updating of treatment by the corresponding treatment provider/ supporter.
• Ensure that all the reports pertaining to programme management from the TU are submitted to the district on time.
• Ensure that all beneficiaries are given Direct Benefit Transfer (DBT) as per the guidelines.
• Ensure that the External Quality Assurance (EQA) of the DMCs under the TU is properly conducted every month.
• Ensure that the STS and the STLS do proper field visits, carry out the supervision and monitoring as per the checklist and give feedback on a periodical basis.

 

Resources 

 

• Training Modules (1-4) for Programme Managers and Medical Officers, NTEP, 2020.
• Technical and Operational Guidelines for Tuberculosis Control, Chapter 9, RNTCP, 2019.
• Module for Senior Treatment Supervisors, RNTCP, 2005. 

 

Assessment 

Question​	Answer 1​	Answer 2​	Answer 3​	Answer 4​	Correct answer​	Correct explanation​	Page id​	Part of Pre-test​	Part of Post-test​
How often should an MO-TC visit a DMC in their area?	Every month	Twice a month	Every quarter	Every day	1	The Medical Officer-TB Control (MO-TC) should cover all Designated Microscopy Centres (DMCs) every month.		Yes	Yes

The District TB Officer (DTO) at the District TB Centre (DTC) has the overall responsibility for the physical and financial management of the National TB Elimination Programme (NTEP) at the district level as per the guidelines.

The DTO is also responsible for the involvement of other sectors in NTEP to ensure better compliance and is assisted by a Medical Officer (MO), statistical assistant and other paramedical staff. For each district, there should be a full-time DTO, who is trained in NTEP.

The Senior Treatment Supervisor (STS) and Senior TB Lab Supervisor (STLS) at the Tuberculosis Unit (TU) level are under the administrative supervision of the DTO/ Medical Officer -TB Control (MO-TC).

The DTO conducts supervisory visits by himself/ herself, or in a team of MO-TC/ STLS/ STS. These visits are conducted on a systematic basis and the protocol to be followed during these visits is shown in the figure below.

 

Figure: Supervisory Protocols for the DTO

Abbr: NTEP: National TB Elimination Programme; NGO: Non-government Organisation

 

The following are the major points to be covered by the DTO under supervision:

 

• All the MO-TCs, the NTEP staff (STS, STLS, TB Health Volunteers (TBHVs), DR-TB-HIV coordinators, PPM coordinators, etc.) are conducting supervisory visits and giving proper feedback on a periodical basis.
• Early diagnosis and treatment initiation are being carried out in the district by all stakeholders.
• Private Practitioners are sensitised adequately and they are notifying all cases of TB in Nikshay.
• Treatment provided by the Public provider is as per the program guidelines and Private practitioners are as per the standards for TB care in India. 
• Public health actions are undertaken in all TB cases notified in Nikshay.
• Direct Benefit Transfer (DBT) is being provided to all beneficiaries as prescribed under NTEP.
• Nikshay recordings are updated and factual.
• External quality assurance is being carried out as per the NTEP protocol.
• Drugs and supplies are supplied uninterruptedly and as per the stocking norms at various levels.
• Microscopes and the other diagnostic equipment including the Nucleic Acid Amplification Test (NAAT) devices are adequately calibrated, and the annual maintenance is being carried out as per protocol.
• All MOs and the staff carrying out TB services in the district are adequately trained. 

 

Resources  

 

• Training Modules (1-4) for Programme Managers and Medical Officers, 2020. 
• Technical and Operational Guidelines for Tuberculosis Control, Chapter 9, RNTCP, 2019. 

 

Assessment  

Question​	Answer 1​	Answer 2​	Answer 3​	Answer 4​	Correct answer​	Correct explanation​	Page id​	Part of Pre-test​	Part of Post-test​
How often should a DTO visit a TB unit in their area?	Every month	Twice a month	Every quarter	Every day	1	The District TB Officer (DTO) should cover all TB units every month.		Yes	Yes

Introduction

Internal Evaluation (IE) is a process of critically evaluating a programme by the programme people to understand determinants of both good and poor performance and enable uptake of the strategic measures for improvement. IE is an integral component of the National Tuberculosis Elimination Programme’s (NTEP) supervision and monitoring strategy.

Objectives of IE

1. To provide a systematic framework for assessing programme performance, financial & logistics management, recording and reporting, and quality of care received by patients.

2. To give recommendations for improving the quality of programme implementation and performance with a realistic action plan and timeline.

3. To monitor efforts to improve and maintain programme quality and performance over time.

Types of IE

IE Methodology

1. Selection of Districts:

At least one good-performing district and one under-performing district should be selected. For states with population up to 30 million – 2 districts per quarter; 30-100 million – 3 districts per quarter; >100 million – 3-4 districts per quarter should be evaluated. In States/Union Territories (UTs) with 4 or less districts, 1 district or Tuberculosis Unit (TU) per quarter may be evaluated.

2. Selection of TB Units/ Designated Microscopy Centres (DMCs):

Five DMCs are selected as follows:

• DMC at District TB Centre (DTC)

• Two DMC that are examining a higher number of TB suspects (preferably from different TU)

• Fourth and fifth DMC are selected randomly from the remaining DMCs (preferably from different TU)

3. Selection of Directly Observed Treatment (DOT) Centres:

The DOT Centres attached to each of the 5 selected DMCs (and Medical College conveniently selected) should be evaluated.

5 additional DOT Centres must be identified in the district with unique characteristics such as those attached to a medical college (other than the one conveniently selected for a visit), other sectors like ESI, Railways, NGOs, private sector, Anganwadi workers, Accredited Social Health Activist (ASHA), community volunteer) and evaluated.

      d) Selection of Patients:

           A total of 36 to 39 patients should be interviewed in the district.

• In each of the 2 DMCs with a low caseload, 4 New Smear Positive (NSP) patients are selected randomly, and one previously treated case conveniently (5 X 2= 10 patients).

• In each of the DMCs at DTC & 2 TU level DMC, 4 NSP patients are selected randomly, and 1 patient, each of the types Relapse, Treatment after Loss to Follow up (LFU) and Failure, are conveniently selected.

• Also select 1 TB/HIV patient and 1 DOTS-Plus  patient (for districts implementing DOTS-Plus) (7 X 3 =21 + 3 +3= 27).

• At least 2 paediatric patients undergoing DOTS treatment within the district must be visited.

IE Activities

Resource

• Supervision and Monitoring Strategy in Revised National Tuberculosis Control Programme; CTD, MoHFW, India, 2012.

• India TB Report 2022; CTD, MoHFW, India, 2022.

Assessment

Question	Answer 1	Answer 2	Answer 3	Answer 4	Correct answer	Correct explanation	Page id	Part of Pre-test	Part of Post-test
Which of the following is an objective of IE?	To provide a systematic framework for assessment of programme performance.	To give recommendations for improving the quality of the programme.	To monitor efforts to improve and maintain programme quality and performance over time.	All of the above	4	The objectives of IE are: 1. To provide a systematic framework for assessment of programme performance, financial & logistics management, recording and reporting, and quality of care received by patients. 2. To give recommendations for improving the quality of programme implementation and performance with a realistic action plan and time line. 3. To monitor efforts to improve and maintain programme quality and performance over time.		Yes	Yes

 

 

 

 

Programme monitoring indicator is a comprehensive tool used to measure and report the performance of the programme from time to time.

Significance 

• Helps to assess the progress of the programme periodically at each hierarchical level.
• Provide insight into the aspects that may have an impact on final outcome. 
• Helps to make decisions on undertaking corrective course of actions whenever required. 

Grouping of programmes monitoring indicators

The national strategic plan (2017-2025) has classified programme monitoring indicators under the four strategic pillars of the End TB strategy which include:

1) Detect:  The indicators included are primarily related to early identification of presumptive TB cases, prompt diagnosis using high sensitivity diagnostic tests and providing universal access to quality TB diagnosis and focuses on TB notification (public and private) and Laboratory and diagnostic services coverage

Examples of Program monitoring indicators under this pillar are:  Total TB patients notified against the target; % of diagnosed TB patients offered rapid molecular test.

2) Treat: The indicators included are primarily related to initiating appropriate anti-TB treatment for all diagnosed TB patients in both public and private and successfully sustaining them on treatment until completion through patient-friendly systems, social support. 

Examples of Program monitoring indicators under this pillar are: Proportion of notified TB patients initiated on treatment in Public and Private; Treatment success rate for RR TB; Proportion of notified TB patients using ICT supported adherence; Proportion of notified TB patients receiving financial support through DBT.

3) Prevent: The indicators included are primarily related to preventing the emergence of TB in susceptible populations and focuses on Air-borne Infection Control (AIC) in secondary and tertiary care settings, diagnosis of Latent TB infection (LTBI) and coverage of TB preventive treatment services.

Examples of Program monitoring indicators under this pillar are:  Proportion of tertiary and secondary facilities with budgeted action plan for AIC in TB facilities; Proportion of identified/eligible individuals for preventive therapy / LTBI s - initiated on treatment.

4) Build: The indicators included are primarily related to building and strengthening enabling policies, empowering the institutions and human resources with enhanced capacities to control and eliminate TB.

Examples of Program monitoring indicators under this pillar are: No. of rapid molecular laboratories established; Proportion of sanctioned positions (newly created positions in this NSP) filled; Proportion of Patient Provider Support Agency (PPSA) units established at the state level; Proportion of electronic drugs and supply chain management systems deployed in the districts.

Resources

NATIONAL STRATEGIC PLAN FOR TUBERCULOSIS ELIMINATION 2017–2025, Central TB Division, Ministry of Health with Family Welfare, India.

India TB Report,2022

 Assessment

Question​	Answer 1​	Answer 2​	Answer 3​	Answer 4​	Correct answer​	Correct explanation​	Page id​	Part of Pre-test​	Part of Post-test​
Which of the following is true about programme monitoring indicators?	Assess the progress of the programme periodically	Provide insight into the aspects that may have an impact on final outcome.	Helps to implement correction course of action	All of the above	4	The programme monitoring indicators: 1) Help to assess the progress of the programme periodically at each hierarchical level. 2) Has the capacity to provide insight into the aspects that may have an impact on final outcome.  3) Helps to make decisions on undertaking corrective course of actions whenever required.	​	Yes	Yes

 

 

 

The Central TB Division assesses the States/ Union Territories (UTs) achievements and performances utilising nine key indicators by using the State TB score.

 

State TB score indicators are shown in the table below and the maximum attainable total score is 100.

S/No	Performance Indicator	Numerator	Denominator	Score
1	% of target TB notification achieved	Total TB patients notified during the defined period	Target TB patients estimated for the year	20
2	% of TB notified patients with known HIV status	Number of patients with HIV status known, i.e., HIV result is either positive or negative/ reactive or non-reactive	Net TB patients notified during the defined period	10
3	% of TB notified patients with Universal Drug Susceptibility Testing (UDST) done	Number of patients with UDST done and rifampicin status known, i.e., rifampicin status is either sensitive or resistant	State benchmark of net TB patients notified during the defined period	10
4	Treatment success rate	Number of TB patients with treatment outcome given as successful, i.e., either cured or treatment completed	Net TB patients notified during the same period	15
5	% of eligible beneficiaries paid under Nikshay Poshan Yojana	TB patients in whom payment has been done at least once	Total eligible TB patients during the same period	10
6	% of multi-drug resistant or rifampicin-resistant (MDR/ RR-TB) patients initiated on treatment out of the total diagnosed	Number of MDR patients initiated on treatment during the defined period	Net MDR patients diagnosed during the defined period	15
7	% of expenditure amongst the approved Record of Proceedings (ROP)	Fund utilised in the defined period	ROP approved during the financial year	10
8	% of children given chemoprophylaxis from the total eligible children identified	Number of children <6 years given Isoniazid chemoprophylaxis	Number of children <6 years eligible for chemoprophylaxis (total children identified- children with active TB detected/ treated)	5
9	% of People living with HIV (PLHIV) given Isoniazid Preventive Therapy (IPT) from the total eligible PLHIV	Number of PLHIV given IPT	Number of PLHIV in whom active TB have been ruled out among the PL attending the Anti-retroviral Therapy (ART) centre	5

 

Resources

• India TB Report, 2021.
• NTEP Training Modules (5-9) for Programme Managers & Medical Officers, 2020.

 

Assessment

Question​	Answer 1​	Answer 2​	Answer 3​	Answer 4​	Correct answer​	Correct explanation​	Page id​	Part of Pre-test​	Part of Post-test​
The State TB score combines nine NTEP performance indicators to rate the performance of states/ UTs.	TRUE	FALSE			1	The State TB score combines nine NTEP performance indicators to rate the performance of states/ UTs.	​	Yes	Yes
Which of the following is not one of the nine NTEP performance indicators?	% of eligible beneficiaries paid under Nikshay Poshan Yojana	% of NTEP districts visited during the quarter (By STO, MO or STDC officials)	Treatment success rate	% of target TB notification achieved	2	% of NTEP districts visited during the quarter (By STO, MO or STDC officials) is not one of the key nine NTEP performance indicators.		Yes	Yes

 

TB Performance Indicator - Percentage of Target TB Notification Achieved

Percentage of Target TB notification achieved is one of the most important indicators to assess the National TB Elimination Programme (NTEP) performance at the state/ UT, district or TB Unit (TU) level.

Indicator	Numerator	Denominator	Multiplier	Data source
% Target TB notification achieved	Total TB cases notified during a defined period	Target TB patients estimated for the year	100	Ni-kshay

Numerator - The data regarding the total TB cases notified in the defined time period is available in Ni-kshay

Denominator - Target TB patients estimated for the year are arbitrarily decided on a yearly basis area-wise based on:

                               1. Trends in previous year's notification

                                 2. Anti-TB drug sale data

                                3. Reports of subnational certification survey/ TB Prevalence  surveys/ other studies, if available

 

The estimated figures are entered in Ni-kshay at the beginning of every year.

 

Example:

The estimated target for TB notifications of District X in the year 2021 is 790. But the number of notified cases in District X in the year 2021 is 510.

% Target TB notification achieved =

                                                                     510 / 790 * 100

                                                        = 72.2%.

                                                (100 % is desirable)

 

Resources

• India TB Report, CTD, MoHFW, GoI, 2022.

 

Assessment

Question​	Answer 1​	Answer 2​	Answer 3​	Answer 4​	Correct answer​	Correct explanation​	Page id​	Part of Pre-test​	Part of Post-test​
What is the denominator of the percentage of Target TB notification achieved?	Total TB cases notified	Prevalent cases of TB	Treatment completed	Target TB patients estimated for the year	4	​Target TB patients estimated for the year is the denominator of the percentage of Target TB notification achieved.

Root Cause Analysis of Low Performance in Percentage of Target TB Notification Achieved

 

Low performance means notification of TB cases is not happening as desired.

Data is available in Ni-kshay and analysed in terms of: 

• Whether the notification is less from a geographical area? (Peripheral Health Institute (PHI)/ TB Unit (TU), private hospital) - Place Analysis 
  • e.g., less notification from a particular PHI may be due to a newly recruited Medical Officer (MO) who is not trained in National TB Elimination Programme (NTEP). The solution should aim at training the MO to improve the notification from that PHI.
• Whether the notification is less in special age group/ gender/ population group?- Person Analysis
  • e.g., teen-aged female patients due to attached stigma. Identification of the stigma by such analysis might be helpful in planning stigma reduction campaigns/ Advocacy, Communication and Social Mobilisation (ACSM) activities to enhance notification.
• Whether there is a change in notification trends across months? - Time Analysis
  • e.g., festive season and marriage season might have less notification, as many patients neglect cough or chronic ill-health. However, this might be dangerous as the probability of spread during such festivals and marriage functions is quite high. Such analysis gives insights for enhanced active case finding during these seasons.

The notification depends on the presumptive TB examination rate. Look at the trends of presumptive examination rate. The expected is about 1500/ lac population.

Some of the reasons and suggested solutions for decreased TB notification are listed below.

Domains	Possible Problems	Suggested Solutions
Patient	Lack of awareness regarding TB symptoms, fear of stigma/ lack of motivation to seek health care Accessibility to health care services Financial reasons	Advocacy communication and social mobilisation (ACSM) Targeted Information, Education and Communication (IEC) for high-risk groups Community mobilisation through Accredited Social Health Activists (ASHA), Non-government Organisations (NGOs), volunteers Steps to set up a Designated Microscopy Centre (DMC), if indicated Steps to minimise out-of-pocket expenditure through mobile testing facilities and point-of-care testing
PHI	Is the poor referral for testing due to: Presumptive TB cases not seeking care Due to deficient knowledge of the staff Due to lack of facilities for sputum collection/ transportation Due to lack of diagnostic services	Vulnerability mapping of all the residents of the PHI area to identify high-risk cases and conduct active and intensified case-finding efforts Provider-oriented IEC, training and periodic reinforcement Arrange facilities for sputum collection and transportation(Hub and spoke model) Enquire regarding the possibility of a DMC in the area
Private Hospital	Deficient knowledge of the provider regarding the NTEP programme/ TB notification Lack of diagnostic facilities Lack of trust in the system or poor rapport with NTEP staff Fear of losing the patient	Provider-oriented IEC, training, capacity building and periodic reinforcement steps for linkage to a diagnostic facility or enquire the possibility of setting up one through the PPP model Steps for private sector engagement Establish a system for diagnosis notification and treatment support for TB cases and supportive supervision
Testing and Diagnosis	Lack of skilled Human Resource (HR) Lack of facilities	Arrange to recruit more HR/ training available HR Periodic training and reinforcement, monitoring and quality check helps Ensure adequate supply chain management Linkage to diagnostic facilities/ set up new facilities
Notification	Not entering the data to Ni-kshay due to: Lack of awareness Technical reasons - internet issues	Training and capacity building along with periodic reinforcement, proper monitoring  Steps to minimise the internet connectivity issues
Other causes	Is the number needed to test to detect one case of TB high? If so, is the estimated target is correct?	Brainstorm with District TB Officer (DTO)/ State TB Officer (STO), and the stakeholders to reach a conclusion

 

Resources

• India TB Report, CTD, MoHFW, GOI, 2022.
• Training Modules (5-9) For Programme Managers & Medical Officers, NTEP, CTD, MoHFW, GoI, 2020.
• National Strategic Plan for Tuberculosis Elimination 2017–2025, NTEP, CTD, MoHFW, GoI, 2017.

 

Assessment

Question	Option 1	Option 2	Option 3	Option 4	Correct answer	Explanation	Page id	Pretest	Post-test
Which of the following is an exception to the steps for improving performance in target TB notification?	Increasing the number of presumptive TB cases examined	By active case finding	By improving diagnostic facilities	By initiating TB treatment	4	Treatment initiation is done after the notification process.

TB Performance Indicator 2 - Percentage of TB Notified Patients with Known HIV Status

 

This indicator monitors efforts taken by the programme to offer HIV testing to all TB patients.

Indicator	Numerator	Denominator	Multiplier	Data source
Percentage of TB notified patients with known HIV status	Number of TB patients  who know their HIV status  in the defined period	Total TB patients notified in the defined period	100	Ni-kshay

 

HIV status of a patient can be reactive, nonreactive or unavailable.

Patients with results as reactive and non-reactive are included in the numerator.

The indicator can be monitored at the TB Unit (TU), district, and state levels.

 

Example:

In District A, the total number of TB cases notified in the year 2020 is 300. Out of them, 240 patients are HIV non-reactive and 10 patients are HIV-reactive as per the data from Ni-kshay.

The percentage of TB notified patients with known HIV status = (240+10) / 300 = (250 * 100) / 300     (100% is desirable)

 

Resources

• India TB Report, CTD, MoHFW, GoI, 2022.
• Training Modules (5-9) For Programme Managers & Medical Officers, NTEP, CTD, MoHFW, GoI, 2020.

 

Assessment

Question​	Option 1​	Option 2	Option 3	Option 4	Correct answer​	Correct explanation​	Page id​	Part of Pre-test​	Part of Post-test​
What is the numerator of the percentage of TB notified cases with Known HIV status?	Total TB cases notified	Total number HIV positive cases	Total number of patients who know their HIV status	Total HIV-negative cases of TB	3	​The number of TB patients who know their HIV status is the numerator of the percentage of TB notified cases with Known HIV status irrespective of whether its positive or negative.

Root Cause Analysis (RCA) for Low Performance in Percentage of TB Notified Patients with Known HIV Status

Low performance in the indicator means that the notified TB cases are not getting HIV tests done as desired.

Analyse the Ni-kshay data and try to gain more insights into the problem. Some examples are given below.

The key questions are

• Who is not knowing the status (Person analysis)? – Are the patients from the public sector or private sector or both? Is it any specific age group (e.g. paediatric) or gender?
• Are there specific geographies where the problems are more (Place analysis)? - Is the issue bigger in a particular TB Unit (TU)/ Peripheral Health Institute (PHI) or is the pattern the same throughout the district?
• Is the low performance specific to any time period (Time analysis)? - Is the performance the same throughout the year or was it different in a particular time period?

Once this is figured out, try to explore the specific reasons for the observations. For that, step-by-step processes that lead to low performance need to be analysed.

 

For the indicator, the key processes are:

(1) Referral for HIV testing by the provider

(2) Patient reach Integrated Counselling and Testing Centres (lCTCs)

(3) Performing an HIV test at the laboratory

(4) Entering the results in Ni-kshay. Ask the above three questions at each process level. Keep on asking questions at each step to get an answer to why is that so.

Discussion with beneficiaries and health providers, and verification of source records would be helpful.

 

Some of the possible causes and suggested solutions are listed below.

Possible causes	Suggested solutions
Poor referral from a provider	Plan for provider-oriented communication, sensitisation and capacity-building of the providers
Patient resistance	Arrange facilities for proper patient counselling/ training of staff on counselling/ using peers for effective counselling
Resistance  to testing in a particular group in the community	Plan targeted advocacy & communication activities
Lack of testing facility	Take steps to set up co-located ICTC/ linked ICTC at the TB detection centre. If the issue is specific to patients notified from the private sector, take steps for linking private health facilities to ICTC or explore the possibility to set up an ICTC/ linked ICTC in private health facilities through the Public Private Partnership (PPP) model
Lack of Human Resources (HR)	Take steps to provide adequate HR/ optimise available HR through redistribution/ train available HR
Poor data entry in Ni-kshay	Measures such as proper monitoring/ training of staff/ sorting out internet issues etc.
Disruption of supply chain	Take steps to resolve the same
Less testing specific to any age group, e.g., paediatric age group	Take measures to sensitise the paediatricians

 

Note: This page describes only an approach for analysis of low performance and has not captured the entire list of problems or solutions. The root cause analysis may be modified according to the local context.

 

Resources

• India TB Report, MoHFW, GoI, 2022.
• Training Modules (5-9) for Programme Managers and Medical Officers, Central TB Division, MoHFW, GoI, 2020.

 

Assessment

Question​	Option 1​	Option 2	Option 3	Option 4	Correct answer​	Correct explanation​	Page id​	Part of Pre-test​	Part of Post-test​
What is the possible cause for the low performance of the indicator- Percentage TB notified with known HIV status?	Poor referral to ICTC	Lack of testing facility	Data entered in Ni-kshay	All the above	4	Poor referral to ICTC, lack of testing facility and data entered in Ni-kshay may all contribute to the low performance of the indicator - Performance TB notified with known HIV status.

TB Performance Indicator - Percentage of TB Notified Patients with Universal Drug Susceptibility Testing (UDST) Done   

 

This indicator measures the efforts by the programme to get the Universal Drug Susceptibility testing done for TB  patients.

Indicator	Numerator	Denominator	Multiplier	Data source
% of TB notified patients with UDST done	Number of TB patients with UDST done	Total number of TB patients notified during  the defined period	100	Ni-kshay

 

• Number of patients with UDST done includes all the TB patients with drug susceptibility testing to at least Rifampicin done.
• UDST is not possible for all TB patients. For example, specimens may not be available for testing in extrapulmonary. The aim is to do UDST for all the cases with specimens available for testing.
• The denominator includes the net notified cases.
• States can set a benchmark to be achieved for this indicator, around 70% is desirable.

 

Example:

In District X, the number of notified TB cases in a year is 600. Out of them, 300 underwent UDST. Out of them, 10 patients are resistant to Rifampicin.

% TB notified cases with UDST done = (300 * 100) / 600 = 50%

 

Resources

• India TB Report, CTD, MoHFW, GoI, 2022.
• Training Modules (5-9) For Programme Managers & Medical Officers, NTEP, CTD, MoHFW, GoI, 2020.

 

Assessment

Question​	option 1​	Option 2	Option 3	Option 4	Correct answer​	Correct explanation​	Page id​	Part of Pre-test​	Part of Post-test​
What is the numerator of the percentage of TB notified cases with UDST  done?	Total TB cases notified	No. of Rifampicin Resistant cases	The total number of patients with  UDST  done	Total  no. of drug-sensitive cases	3	​The total number of patients with  UDST done is the numerator of the percentage of TB notified cases with UDST done.

Root Cause Analysis of Low Performance in Percentage of TB Notified Cases with Universal Drug Susceptibility Testing Done  

Low performance means Universal Drug Susceptibility Testing (UDST) is not done for the notified TB patients as desired.

At the TB Unit (TU) level, obtain the list of patients not offered UDST from Ni-kshay. Write against each patient why UDST is not offered. Analyse the reasons.  

• Who is not offered UDST (Person analysis)? - Are these patients from the public sector or private sector or both?  
• Are there specific geographies where the problems are more (Place analysis)? - Is the issue bigger in a particular TU/ Peripheral Health Institute (PHI) or is the pattern the same throughout the district?
• Is the low performance specific to any time period (Time analysis)? - Is the performance the same throughout the year or was it different in a particular time period?

Once this is figured out, try to explore the specific reasons for the observations.

Step-by-step processes which lead to low performance is to be analysed.

 

For the indicator the key processes are:

a) Patient referral for testing

b) Availability of specimens for testing

c) Specimen reaching the testing facility

d) Testing the specimen

e) Entering the report in Ni-kshay.

 

Explore the processes to answer the specific observations obtained during the initial analysis.

Keep on asking questions at each step to get an answer to why is that so. 

Discussion with beneficiaries and health providers, and verification of source records would provide more insight to the underlying cause.

 

A few possible causes and suggested solutions are given below.

Possible Causes	Suggested Solution
Poor referral from the provider (public or private)	Plan for provider-oriented communication, sensitisation, and capacity building of the providers
Difficulty in extracting extrapulmonary specimens/ specimens other than sputum	Linkages with facilities for specimen extraction/ train providers for extracting specimens
Issues in the transportation of the specimen to the testing centre	Arrange facilities for specimen collection and transportation (Hub & spoke model)
Lack of testing facilities	Explore the possibility to set up Nucleic Acid Amplification Testing (NAAT) facilities/ starting in the private sector through partnership schemes
Disruption of supply chain	Identify the cause and take steps to resolve the same and explore the possibility to outsource the testing till the supply chain resumes
Incomplete data entry in Ni-kshay	Proper monitoring/ training of staff/ sorting out internet issues etc.

 

 

 

 

 

 

 

 

 

                                                     

                                                      

 

             

 

                     

 

 

 

 

 

 

Note: This page describes only an approach for analysis of low performance and has not captured the entire list of problems or solutions. The root cause analysis may be modified according to the local context.

 

Resources

• India TB Report, MoHFW, GoI, 2022.
• Training Modules (5-9) for Programme Managers and Medical Officers, Central TB Division, MoHFW, GoI, 2020.

 

Assessment

Question​	Option 1​	Option 2	Option 3	Option 4	Correct answer​	Correct explanation​	Page id​	Part of Pre-test​	Part of Post-test​
Select the probable reason for low performance in the percentage of notified cases with UDST done.	Poor provider referral	Lack of testing facility	Lack of specimen transportation facility	All the above	4	Poor provider referral, lack of testing facility and lack of specimen transportation facility may contribute to low performance in the percentage of notified cases with UDST done.

Root Cause Analysis for Low Performance in Treatment Success Rate

 

Low performance in treatment success rate means the notified patients are not completing the treatment or cured of TB as desired.

Unsuccessful treatment outcomes are:

(a) Death       

(b) Lost to follow-up 

(c) Treatment failure

 

Analysing Ni-kshay data would give information on which among the unsuccessful outcomes requires attention. Analyse the data in terms of:

1. Who didn’t successfully complete the treatment (Person analysis)? - Was it high in TB cases notified from the public sector/ private sector? Those with co-morbidities/ addiction? Of any specific gender? Of any specific age group?
2. Are there specific geographies where the problems are more (Place analysis)? - Is the issue bigger in a particular TB Unit (TU)/ Peripheral Health Institute (PHI), in any population group residing in a specific area?
3. Is the low performance specific to any time period (Time analysis)? - Is the performance the same throughout the year or was it different in a particular time period?

Case to case audit of unsuccessful outcomes could provide insights into the reasons for the unsuccessful outcomes. Analysing audit reports could help to identify the underlying preventable cause if any.

 

Possible Causes	Suggested Approach to Data Analysis	Suggested Solutions to Minimise Poor Treatment Outcomes
Was there a delay in diagnosis leading to death?	Calculate the mean/ median time period between the date of onset of symptoms and the date of TB diagnosis. Date of onset to be obtained from death audit forms/ patient’s relative’s interview.	Strengthen case-finding efforts through Active Case Finding (ACF), Intensified Case Finding (ICF) and strengthening passive case finding Arrange for sensitisation if the delay is due to a training issue. Examine the diagnostic centre linkage and arrange for linkage if that is an issue.
Was there a delay in the initiation of treatment leading to death?	Calculate the mean/median time period between the date of diagnosis of TB and the date of treatment initiation (Both are available in Ni-kshay).	Explore the reasons for the delay in treatment initiation and address them. Arrange for sensitisation if the delay is due to a training issue. Examine the supply chain management and if there is a problem, solve it.
Was the treatment adherence poor?     Was the lost to follow-up after treatment initiation high?	Monitor and analyse the adherence dashboards and Loss to Follow-up (LFU) rates from Ni-kshay.   Analyse geography-wise/ gender-wise to see if it is poor in some specific areas/ there was a gender-based or age-based stigma.	Find out the further underlying cause and address it. Assess the counselling skills of the provider and sensitise if that is an issue. Check if the treatment supporter is monitoring the treatment adherence regularly. Solve if there is a problem. See if Additional Drug Requirements (ADRs) were timely addressed, and sensitise the stakeholders as applicable. Strengthen linkage to de-addiction services. Establish treatment support groups to address gender/ age-wise stigma in geographies with higher LFU.
Was there a delay in diagnosis of drug resistance leading to treatment failure/ death?	Calculate the mean/ median time period between the date of diagnosis of TB and the date of offering Rifampicin resistance testing/ Isoniazid resistance testing.	Explore the further underlying factors and address the same to minimise the delays Check if Universal Drug Susceptibility Testing (UDST) protocols were adhered to, and sensitise as appropriate.  Check the linkage to the UDST facility, and arrange if there is a problem.
Were co-morbidity/ ADRs detected timely and managed properly?	Death audit reports/ patient’s relative’s interviews/ review of records.	Check if differentiated TB care is provided as per protocol, and sensitise as appropriate.  Establish a system for differentiated TB care. Train treatment supporters for TB cases with ADR and comorbidity. Sensitise stakeholders for timely referral and clinical follow-up.
Is it due to the movement of TB  cases from one place to another (e.g. migrants/ change in residence after marriage)?	Is it due to a lack of information about ‘transfer’ cases? Find out the areas from where the ‘out of area’ patients are there without treatment outcomes.	Establish a system for follow-up of transfer-out cases. Coordinate closely with the concerned TU/ district/ state to prevent duplicate entry and proper transfer systems through Ni-kshay.
Is the problem related to an information gap?	Is there a deficiency in reporting treatment outcomes from the private sector?	Sensitise/ train private providers, and establish systems for supporting private providers in recording treatment outcomes.

 

Resources

• India TB Report, CTD, MOHFW, GOI,2022.
• Training Modules (5-9) for Programme Managers and Medical Officers, Central TB Division, MoHFW, GoI, 2020.

 

Assessment

Question	Option 1	Option 2	Option 3	Option 4	Correct Answer	Correct explanation	Page id	Part of pre-test	Part of post-test
Which of these is a false statement related to the poor performance in treatment success rate?	Poor management of ADR is a cause.	Delay in the initiation of treatment is a cause.	Death audits are not helpful to find out the cause.	Treatment support groups are helpful for treatment adherence.	3	Death audits are helpful in finding the cause of poor performance in treatment success rate.

NTEP Performance Indicator - Percentage of Eligible Beneficiaries Paid Under Ni-kshay Poshan Yojana

This is an indicator used to monitor the implementation of Ni-kshay Poshan Yojana (NPY) scheme.

Indicator	Numerator	Denominator	Multiplier	Data source
Percentage eligible beneficiaries paid under Ni-kshay Poshan Yojana	Number of TB patients to whom payment has been done at least once	Total eligible TB patients  within the same period	100	Ni-kshay

 

• All the notified TB cases are eligible for Direct Benefit Transfer (DBT) under NPY.
• All the patients who received at least the first payment are included in the numerator.
• The performance can be monitored at the TB Unit (TU) level/ district level/ state level

 

Example:

In a TU, there are 100 notified cases of TB in the year 2021. 80 of them received the first payment from Ni-kshay Poshan Yojana scheme. Among the 80 persons, 20 had received the 2nd payment also.

 

% Eligible beneficiaries paid under NPY = {80 / (80+ 20)} * 100 = 80%

 

Resources

• India TB Report, CTD, MoHFW, GoI, 2022.
• Training Modules (5-9) For Programme Managers & Medical Officers, NTEP, CTD, MoHFW, GoI, 2020.

 

Assessment

Question​	Option 1​	Option 2	Option 3	Option 4	Correct answer​	Correct explanation​	Page id​	Part of Pre-test​	Part of Post-test​
What is the numerator of the percentage of eligible beneficiaries under Ni-kshay Poshan Yojana?	Those who received all the eligible payments only	Those who received two instalments	Those who received at least the first payment	None of the above	3	​Those who received at least one payment are included in the numerator of the percentage of eligible beneficiaries under Ni-kshay Poshan Yojana.

Root Cause Analysis for Low Performance in the Percentage of Eligible Beneficiaries Paid under Ni-kshay Poshan Yojana

 

Low performance means the notified TB cases have not received even the first payment through Direct Benefit Transfer (DBT) under the Ni-kshay Poshan Yojana (NPY) as desired. 

Obtain the data from Ni-kshay and analyse it in terms of:

• Who all have not received the payment (Person analysis)? - Any specific pattern? Patients notified from the public sector/ private sector, specific age group (paediatric or elderly), a specific gender, specific group (migrant labourers), or those without a bank account.
• Whether the problem is more in a specific geography (Place analysis)? - Is the issue bigger in a particular TB Unit (TU)/ Peripheral Health Institute (PHI), in any population group residing in a specific area (e.g., hard-to-reach pockets)?
• Is the low performance specific to any time period (Time analysis)? - Is the performance the same throughout the year or was it low in a particular time period (e.g., April, May due to shortage of funds)? 

 

The Process of DBT 

 

1. Entry of each TB patient with a bank account and Aadhaar in Ni-kshay and its follow-up details (at PHI level)
2. Preparation of beneficiary list (at PHI level)
3. Checking of beneficiary details (at TU level)
4. Approval of beneficiary list with details (at district level)
5. Processing of payment (Public Financial Management System - PFMS portal) (at district level)

A breach in any of the processes will lead to the non-delivery of DBT.

Discussion with beneficiaries and health providers, and verification of source records would be helpful for further analysis.

 

	Possible Causes	Suggested Solutions
Are the bank account and Aadhar details entered in Ni-kshay? If No	Deficient knowledge of provider (public/ private) No bank account or Aadhar card for TB patients Not willing to share bank account details or Aadhar details due to lack of awareness or confidentiality issues	Provider-oriented Information, Education and Communication (IEC) and capacity building. Volunteer groups can be created to help illiterate and elderly to get Aadhar card/ bank account  If the problem is in a particular group of the population like: Migrant labourers - coordinate with the labour department Tribal population - coordinate with the tribal promoter. Destitute - establish a system with volunteers/ NGO  Patient-oriented IEC.
Was there any delay in the preparation checking and approval of the list? If Yes	Shortage of Human Resources (HR) Deficient knowledge of staff Technical problems	Take steps to provide adequate HR/ optimise available HR through redistribution/ train available HR. Address the gaps in training. Take measures such as proper monitoring/ training of staff/ sorting out internet issues.
Was there any delay in processing the payment? If yes	Technical issues at Ni-kshay - PMFS interface Shortage of HR	Take measures such as proper monitoring/ training of staff/ sorting out internet issues/ network issues. Take steps to provide adequate HR/ optimise available HR through redistribution/ train available HR.
Is it due to patient refusal of DBT?	Confidentiality issues Salaried and rich may deny DBT	IEC to address confidentiality issues. Document "refusal".
Is it due to other causes?	Lost to follow-up (LFU)/ Death/ Transfer out	Measures to minimise LFU. Document "death". Coordinate closely with the concerned TU/ district/ state to prevent duplicate entry and proper transfer systems through Ni-kshay.

 

Resources

• India TB Report, CTD, MoHFW, GoI, 2022.
• Training Modules (5-9) for Programme Managers and Medical Officers, Central TB Division, MoHFW, GoI, 2020.

 

 

Assessment

Question	Option 1	Option 2	Option 3	Option 4	Correct answer	Correct explanation	Page ID	Pre-test	Post-test
Which of the following is not a cause of low performance in Ni-kshay Poshan Yojana?	No bank account for beneficiaries	Denial of DBT	Good adherence to drugs	Technical difficulties	3	No bank account for beneficiaries, denial of DBT and technical difficulties - all are causes of poor performance.

Root Cause Analysis of Low Performance in Percentage of Rifampicin-resistant (RR)/ Multidrug-resistant (MDR)-TB Cases Initiated on Treatment out of the Total Diagnosed

 

Low performance means the diagnosed cases of MDR/ RR-TB cases are not started on treatment as desired.

Obtain the data from the Programmatic Management of Drug-resistant TB (PMDT) quarterly report and Ni-kshay and analyse in terms of:

• Who was not initiated on treatment? (Person Analysis) - Patients from the public sector or private sector, of any specific age group (elderly or paediatric), of any specific gender.
• Whether the problem is more in a specific geography? (Place Analysis) - Patients from a particular TB Unit (TU)/ Peripheral Health Institute (PHI)? Patients staying in specific geographical areas (difficult to access areas).

Once this is done, analyse at the process level. The process is:

1. Patient diagnosed as RR/ MDR-TB in the lab and data entered in Ni-kshay
2. Patient should be traced (at PHI/ private hospital) and information disclosed
3. Pretreatment evaluation
4. Initiation of treatment

Case to case audit can be done to find the cause against each patient.

Discussion with patients, treatment supporters and verification of source records may be done to get more information.

Examine if there is a pattern - e.g., only patients from one particular place (may be hard to reach area) are not initiated on treatment.

There may not be a single pattern. Then examine the most common patterns.

Understanding the underlying cause is important to address the problem in an efficient manner.

	Possible Causes	Suggested Solutions
Is there any problem in patient tracing and contact at PHI/ private hospital level?	Contact information not available in Ni-kshay Incorrect address No contact number	Assign one Drug-resistant TB (DR-TB) coordinator for the patient and entrust him for the follow-up. Ensure correct data entry in Ni-kshay. Double check the address with id at Ni-kshay entry. Proper training and capacity building of the staff for the same. Procure more than one contact number. Seek the help of a Local Self Government (LSG) representative. If the patient has moved out of the area, take measures to trace and transfer out to the respective area.
Patient resistance	Fear Apprehension Lack of family support  No bystanders	Proper counselling of the patient and the immediate relative at the time of disclosure of the result is very important. Counselling should be provided at each stage. An immediate relative can be counselled and trained to be a treatment supporter of the patient.  Seek cooperation from Non-government Organisations (NGOs)/ volunteers.
Is there any issue in pretreatment evaluation?	Distance to the testing facility Cost of evaluation Multiple visits needed Delay in getting the reports Transportation issues	Arrange for patient-centric quality services at a government facility to avoid patient discomfort. Outsource in a partnership model in areas where facilities are not available.  Arrange for transportation or refund of travel expenses.
Is there a delay in the initiation of treatment?	Patient resistance Delay in results of pretreatment evaluation Distance from the treatment centre	Counselling  Fast-tracking the report OPD-based treatment Setting up a decentralized treatment facility Arranging for transportation or reimbursement for travel
Do the patients from the private sector have issues in starting treatment?	Patient wants to continue the clinical services from the private provider, but drugs are not available. Patient wants to change the treatment to a public health facility.	Coordinate with the hospital management and provide the drugs and necessary support. Linkage through Public Private Partnership (PPP)  Arrange for the patient transfer to a public health facility.
Other causes	Duplication of data entry leading to an inflated denominator (total diagnosed cases) Issues with data entry in Ni-kshay	Proper monitoring to avoid duplication  Training, monitoring of staff Sort out internet connectivity issues

 

Note: This page describes only an approach for analysis of low performance and has not captured the entire list of problems or solutions. The root cause analysis may be modified according to the local context.

 

Resources

• India TB Report, CTD, GoI, 2022.
• TB Training Modules (5-9) for Programme Managers and Medical Officers, NTEP, CTD, MoHFW, GoI, 2020.
• Guidelines for Programmatic Management of Drug-resistant Tuberculosis in India, NTEP, CTD, MoHFW, GoI, 2021.

 

Assessment

Question	Option1	Option 2	Option 3	Option 4	Correct answer	Explanation	Page id	Pretest	Post-test
Which of the following does not minimise the delay in treatment initiation/ treatment not initiated for MDR-TB cases?	Timely tracing of the patient	Proper counselling of the patient	A trained treatment provider	Not offering drugs to private patients	4	Timely tracing of the patient. proper counselling of the patient, a trained treatment provider will help minimise the delay in treatment initiation.

NTEP Performance Indicator - Percentage Expenditure Against Approved Record of Proceedings (ROP)
 

 This indicator measures the utilisation of the allocated budget for the National TB Elimination Programme (NTEP) and thereby assess programme implementation.

Indicator	Numerator	Denominator	Multiplier	Data source
Percentage expenditure against approved ROP	Fund utilised in the defined period	ROP as approved during the financial year	100	Public Financial Management System, GOI

 

• The numerator includes the amount utilised for various activities under programme/ implementation at district/ state levels.  
• Record of proceeding is finalised at each level based on the Programme Implementation Plan (PIP) at the corresponding level (district/ state).

 

 Example:

The ROP approved for District X for NTEP activities is Rs 1.2 crore for the financial year 2018-2019 and Rs 1.1 crore is utilised in the same financial year.

The percentage expenditure amongst the approved ROP = (11000000 / 12000000) * 100 = 91.6%

 

Resources

• India TB Report, CTD, MoHFW, GoI, 2022.
• Training Modules (5-9) For Programme Managers & Medical Officers, NTEP, CTD, MoHFW, GoI, 2020.

 

Assessment

 

Question​	Option 1​	Option 2	Option 3	Option 4	Correct answer​	Correct explanation​	Page id​	Part of Pre-test​	Part of Post-test​
What is the numerator of percentage expenditure amongst approved ROP?	Total fund allocated for the financial year	Fund utilised in the financial year	Both 1 and 2 added	ROP approved for the financial year	2	​Fund utilised in the financial year is the numerator of percentage expenditure amongst approved ROP.

Root Cause Analysis for Low Performance in Percentage Expenditure Against Approved Record of Proceedings (ROP)

 

Low performance means the fund for National TB Elimination Programme (NTEP) is not utilised as expected.

The data for the same is available in Public Financial Management System (PFMS) portal and the non-utilisation of funds can occur in two scenarios:

1. Absent or delayed fund flow

2. Non-utilisation of the already available fund

 

Analyse the data as follows:

• Is the low performance noticed during a particular time period? (Time Analysis) - Fund flow less during the first half of financial year? More fund flow towards the end of financial year/ less utilisation in which quarter? Further explore reasons for low expenditure during a specified time, if any.
• Is there delayed flow/ underutilisation particular to a TB Unit (TU)? district ? or is it uniform through out the state? (Place Analysis) - Further explore the reason for delayed release/ under-utilisation in a particular TU/ district, if any.

There is a total of 19 indicative norms under NTEP budgeting. Compare the utilisation against each indicative norm of the approved ROP.

The initial allocation will be based on cash flow forecasts of NTEP (based on their action plan and budgets). Subsequent funds will be released based on expenditures and projected requirement for release of funds.

 

Timely AUDIT needs to be done to ensure proper fund utilisation under each head.

	Possible Causes	Suggested Solutions
Delayed/ Absent fund flow	Lack of convergence and intersectoral coordination Complex fund flow mechanism Timely submission of expenditure may NOT happen due to: Technical issues Shortage of Human Resource (HR)	High prioritisation of the programme by the government to avoid the delay System/ team in place for the intersectoral coordination Strong monitoring and timely submission of reports Training and capacity building of HR Finding the cause and sorting it - ensuring internet connectivity, capacity building of staff Adequate recruitment of HR/ training available HR
Under-utilisation of fund	Absence of proper auditing Technical reasons  Less spending under certain heads  Shortage of HR Communication gaps/ miscommunication	Transparent auditing of the expenses Fast tracking the activities where fund utilisation is low by comparing with Programme Implementation Plan (PIP) Adequate recruitment of HR/ training available HR Establishing a system/ channel for proper communication Regular monitoring of budgetted activities and expenditure

 

Note: This page describes only an approach for analysis of low performance and has not captured the entire list of problems or solutions. The root cause analysis may be modified according to the local context.

 

Resources

• India TB Report, CTD, MoHFW, GoI, 2022.
• Training Modules (5-9) For Programme Managers & Medical Officers, NTEP, CTD, MoHFW, GoI, 2020.
• National Strategic Plan for Tuberculosis Elimination 2017–2025, NTEP, CTD, MoHFW, GoI, 2017.

 

Assessment

Question	Option 1	Option 2	Option 3	Option 4	Correct answer	Explanation	Page id	Pretest	Post test
What are the possible causes of low percentage fund utilisation against approved ROP?	Delay in fund flow	Absence of proper auditing	Lack of intersectoral coordination	All the above	4	Delay in fund flow, absence of proper auditing and lack of intersectoral coordination are all causes of poor performance.

NTEP Performance Indicator - Percentage of Children given Chemoprophylaxis from the Total Eligible Children Identified

This indicator measures the capacity of the programme to initiate TB Preventive Treatment  (TPT) in children < 5 years of age eligible for the same.

 

Indicator	Numerator	Denominator	Multiplier	Data source
Percentage of Children given Chemoprophylaxis from the Total Eligible Children Identified	Number of children less than 5 years of age  given chemoprophylaxis	Number of children less than 5 years of age eligible for chemoprophylaxis	100	Ni-kshay

 

• Numerator - Number of children < 5 years started on chemoprophylaxis as part of TPT
• Denominator - Number of children < 5 years of age who are eligible for TB preventive treatment are children < 5 years who are household contacts of microbiologically confirmed pulmonary TB. The children who are household contacts diagnosed to have active TB/ on TB treatment are to be excluded from the denominator.

 

Example:

In the TU named X, a few children were identified to be household contacts of TB cases.

10 of them were less than 5 years of age.

Out of the 10 children,7 were exposed to microbiologically confirmed pulmonary TB.

One of them was identified to have active TB disease. TPT was started for 5 children.

Total children <5 years eligible for TPT = 7-1 = 6 (1 child was excluded as he had active TB)

Those who received TPT = 5

Percentage of Children given Chemoprophylaxis from The Total Eligible Children Identified = (5 / 6) * 100 = 83.3%, whereas 100% is desirable.

 

Resources

• India TB Report, MoHFW, GoI, 2022.
• Training Modules (5-9) for Programme Managers & Medical Officers, NTEP, CTD, MoHFW, GoI, 2020.

 

Assessment

Question​	Option 1​	Option 2	Option 3	Option 4	Correct answer​	Correct explanation​	Page id​	Part of Pre-test​	Part of Post-test​
What is the correct statement about the denominator of the percentage of children given chemoprophylaxis from the total eligible children?	Children < 5 years who are household contacts of any form of TB are  included	Children < 5 years who are household contacts and found to have active TB to be excluded	Children < 5 years who are household contacts of microbiologically confirmed pulmonary TB are included	Both 2 and 3	4	​Children < 5 years who are household contacts of microbiologically confirmed pulmonary TB (excluding household contacts diagnosed to have active TB/ on TB treatment) are denominator of the percentage of children given chemoprophylaxis from the total eligible children.

 Root Cause Analysis in Percentage of Children given Chemoprophylaxis from the Total Eligible Children Identified

 

The low performance means the children less than 5 years of age who are eligible for chemoprophylaxis are not receiving it as desired.

The data is available in Ni-kshay; analyse it in terms of :

• Who did not receive the chemoprophylaxis? (Person Analysis) - Are they contacts of cases notified from the public sector/ private sector, of a specific gender or population group?
• Whether they belong to a specific geographic area? (Place Analysis) - Specific Peripheral Health Institute (PHI)/ TB Unit (TU)? Difficult to access area?
• Is poor performance in a particular time period? (Time Analysis) - If yes, is it uniform for all cases throughout a specific time period?

 

Process involved in Tuberculosis Preventive Treatment (TPT) for children less than 5 years:

1. Complete contact tracing of the index case 
2. Rule out active TB
3. Prepare the list of children less than 5 years eligible for treatment
4. Initiate and complete TPT

 

Case to case audit of the eligible children who did not receive chemoprophylaxis to find the cause can be done.

Obtain more information from the parents, health care workers and source records.

Some of the causes are listed below.

	Possible Causes	Suggested Solutions
Was the child initiated on treatment? If No	Patient-related causes: Deficient information about the parents and lack of risk perception Apprehension regarding the medications and side effects Confidentiality issues Moved out of the place/ migrant   Provider-related causes: Deficient knowledge of the provider (public or private) Shortage of Human Resource (HR)	Proper counselling and education of the parents/ primary caregivers and the head of the family regarding the need for chemoprophylaxis and gaining the confidence of the family Training the primary caregiver regarding proper administration, common side effects  Follow-up and proper transfer out to the concerned TU Duplication to be avoided     Provider targeted Information, Education, Communication (IEC), capacity building through trainings so that they are aware of the updated guidelines Steps to provide adequate HR/ train available HR
How is treatment adherence?	Is non-adherence due to: Non-palatability of the drugs for the child? Adverse Drug Reaction (ADR)? Inadequate knowledge of the parents, on what to do on missed doses? Poor monitoring of the treatment adherence by the providers?	Discussing with the paediatrician and finding a suitable solution Timely identification and management of ADR Facilitating proper communication of the parents with the National TB Elimination Programme (NTEP) staff Entrusting the responsibility to a particular staff and proper monitoring
Is it due to the non-availability of drugs?	Disruption in supply chain management	Finding the cause and addressing it
Are there any issues in reporting?	Problems with data entry in Ni-kshay	Proper monitoring/ training of staff/ sorting out internet issues etc.

 

Note: This page describes only an approach for analysis of low performance and has not captured the entire list of problems or solutions. The root cause analysis may be modified according to the local context.

 

Resources

• India TB Report, CTD, GoI, 2022.
• TB Training Modules (5-9) for Programme Managers and Medical Officers, NTEP, CTD, MoHFW, GoI, 2020.
• Collaborative Framework to Address the Burden of Tuberculosis among Children and Adolescents, MoHFW, 2021.

 

Assessment

Question	Option1	Option 2	Option3	Option 4	Correct answer	Explanation	Page id	Pretest	Post-test
Which of these is not a possible cause for poor performance in percentage chemoprophylaxis for eligible children?	Parent apprehension	Ignorance of the provider	Child moving out of the area and lost-to-follow-up	Regular follow-up	4	Regular follow-up cannot be the possible cause for poor performance in percentage chemoprophylaxis for eligible children.

Performance Indicator - Percentage of People Living with HIV (PLHIV) given INH Preventive Treatment (IPT) Against Total Eligible PLHIV

Measures the capacity of the programme to initiate TB preventive treatment for all individuals with HIV who are eligible for the same.

Indicator	Numerator	Denominator	Multiplier	Data source
Percentage of People Living with HIV (PLHIV) given INH Preventive Treatment (IPT) against total eligible PLHIV	Number of PLHIV given IPT in the defined period	Number of PLHIV enrolled in the Antiretroviral Therapy (ART) clinic in a defined period	100	National AIDS Control  Organisation (NACO)

• Numerator - Number of PLHIV given IPT in the defined period  includes All the eligible HIV Patients started on INH Preventive Therapy in a defined time period 
• Denominator - Number of PLHIV enrolled in the ART clinic in the defined period includes all the new HIV cases enrolled in the ART clinics without active TB disease in a defined time period. Those who are already on TB treatment should also be excluded.                                    

Example:

The total number of HIV patients newly registered in an ART clinic from Jan-Dec 2019 is 100. Out of them, 10 were already on TB treatment, 10 were newly detected to have TB and 78 people were started on IPT.

Percentage of PLHIV given IPT against total eligible PLHIV = (78 / 80) * 100 = 97.5%

Resources

• India TB Report, MoHFW, GoI, 2022.
• Training Modules (5-9) for Programme Managers & Medical Officers, NTEP, CTD, MoHFW, GoI, 2020

Assessment

Question​	option 1​	Option 2	Option 3	Option 4	Correct answer​	Correct explanation​	Page id​	Part of Pre-test​	Part of Post-test​
What is the correct statement about the denominator of the Percentage of PLHIV given IPT against total eligible PLHIV?	Does not Include HIV cases with active TB disease	Does not include HIV cases on TB treatment	Both 1 and 2	All cases started on INH chemoprophylaxis  are included	3	​Denominator for Percentage of PLHIV given INH Preventive Treatment (IPT) against total eligible PLHIV includes number of PLHIV enrolled in the ART clinic in the defined period includes all the new HIV cases enrolled in the ART clinics without active TB disease in a defined time period. Those who are already on TB treatment should also be excluded.

Root Cause Analysis of Low Performance in Percentage of People Living with HIV (PLHIV) given Isoniazid (INH) Preventive Treatment (IPT) Against Total Eligible PLHIV

Low performance means the eligible PLHIV are not getting the INH preventive therapy as desired. The data is available with National AIDS Control Organisation (NACO) and analyse it in terms of: 

• Who is not getting INH chemoprophylaxis? (Person Analysis) - Are people of any specific age group or is there any gender difference?
  • This may indicate certain stigma, beliefs, or awareness problem in certain category of people - the approach to solution may be different.
• Whether they are from specific geography? (Place Analysis) - Any specific Antiretroviral Therapy (ART) centre or some specific area or a population or occupation group?
  • There may be training issue with certain providers, or accessibility issues with certain groups - a separate strategy may be needed to address them.
• Whether the low performance is specific to any time period? (Time Analysis)
  • This analysis, for e.g., may indicate certain supply chain issues during a sepcified period - then the strategy may be different for addressing the same.

 

The process of IPT implementation in a patient visiting the ART clinic is as follows: 

1. TB symptom screening 
2. IPT assessment for those who are SS negative and IPT card, if eligible
3. IPT collection from the ART pharmacy
4. Recording and reporting in IPT register

A breach/ delay in any of the above process will cause delayed or non-initiation of INH.

Collecting information from ART centre staff, PLHIV, source records will help in analysis of each case.

 

	Possible Causes	Suggested Solutions
Was the symptom screening for TB done and the decision on IPT made? if No	Deficient knowledge of health care provider Proxy attendance to collect ART/ collecting drugs from Link ART / lost to follow-up	Capacity building of the healthcare provider, periodic refresher training All cases registered at ART centre should get the symptoms screened and decision on IPT at the first visit itself Arrange for transportation facilities/ reimbursement
Was the patient started on INH? If No,   Was there a delay/ non initiation in children and elderly?	Resistance from patient due to inadequate knowledge, stigma, or fear of pill overload or adverse effects Shortage of drugs   Adequate knowledge of ART centre staff Apprehensive patients/ parents  Alcoholism/ comorbidity of the patient	Proper counselling of the patient  Demand generation Peer group support Proper supply chain management to ensure continuous supply of drugs Capacity building and periodic training Patient/ caregiver counselling Facilities for deaddiction/ comorbidity management
Was there an information gap?	Non-maintenance of details entered IPT register and monthly IPT report	Training and capacity building of the ART centre staff and proper monitoring.

 

Note: This page describes only an approach for analysis of low performance and has not captured the entire list of problems or solutions. The root cause analysis may be modified according to the local context.

 

Resources

• India TB Report, CTD ,GoI, 2022.
• Technical and Operational Guidelines for Tuberculosis Control in India, CTD, MoHFW, GoI, 2016.

 

Assessment

Question	Option 1	Option 2	Option 3	Option 4	Correct answer	Explanation	Page id	Pretest	Post-test
What are the possible reasons for PLHIV not getting IPT as expected?	Deficient knowledge of the provider	Resistance from patient	Lack of drugs	All the above	4	All the mentioned reasons can be the possible cause for PLHIV not getting IPT as expected.

Monitoring and Evaluation (M&E) refers to the set of activities used to assess the progress of a programme towards specific objectives and address weaknesses in the programme design.

Monitoring

It is a systematic, ongoing collection, collation, analysis and interpretation of the data to detect deviations from the expected norms, followed by dissemination of feedback information for corrective actions.

Significance of Monitoring

• Ensure that activities are implemented as planned
• Verifies that the data recorded and reported is accurate and valid

• Provides evidence for making mid-course correction decisions

   

Evaluation

A systematic method for collecting, analysing, and using data mainly to examine the effectiveness and efficiency of the program for continuous program improvement. The evaluation consists of process evaluation, outcome evaluation and impact evaluation.

Significance of Evaluation

• Estimates the programmatic costs for implementation
• Measures the programme coverage
• Assess the TB treatment outcomes
• Assess the impact of implemented activities

 

Under the National TB Elimination Programme (NTEP), monitoring is conducted at various levels - Central, State, District, Tuberculosis Unit (TU) and Peripheral Health Institutes (PHIs) and the respective authorities at each of these units are responsible for the same, whereas evaluation is conducted mainly at the central and state level.

The programme has designed an M&E framework and is revising it time to time. NTEP’s Ni-kshay application facilitates case-based real-time monitoring of all the major programmatic indicators.

 

Resources

• Training Modules (5-9) for Programme Managers & Medical Officers, NTEP, CTD, 2020.
• Compendium of Indicators for Monitoring and Evaluating National Tuberculosis Programmes, WHO, 2004.

 

Assessment

Question​	Answer 1​	Answer 2​	Answer 3​	Answer 4​	Correct answer​	Correct explanation​	Page id​	Part of Pre-test​	Part of Post-test​
Monitoring and evaluation play an important role in which of the following?	Assess the programme activities	Measure programme effectiveness	Identify problem areas	All of the above	4	Monitoring and evaluation play an important role in assessing the programme’s effectiveness and activities and identifying problem areas.	​

Nikshay is an Integrated ICT system for TB patient management and care in India. Nikshay was launched in 2012 and since then, various improvements have been made in the system.

Nikshay provides-

• A Unified interface for public and private sector health care providers
• Different types of Logins such as State, District, TU, PHI, Staff logins, Private providers, Chemist, Labs and PPSA/JEET Logins
• Integration of all adherence technologies such as 99DOTS and MERM
• Unified DSTB and DRTB data entry forms
• Mobile friendly website with mobile app

Nikshay is accessible either via web browser(https://Nikshay.in ) or mobile App called ‘Nikshay’ that can be downloaded from Google Play Store(Android).

Figure: Nikshay Login Pages

This is a list of all deleted records based on diagnosis date & as per all three health facilities (Enrollment, Diagnosing and current).

This register provides details such as date of deletion of the record and reason of deletion by user along with details of health facilities (Enrollment, Diagnosing and current).

 

Video: Deleted Patient Register

Video: Prescription Register

This is a line list of confirmed DRTB cases on treatment based on current health facilities.

Description: This register gives details about the tests and final interpretation based on the treatment start date and notification date:

• Health Facility ( Diagnosing & current facility details, ie.. State/District/ TU/PHI).
• Date of diagnosis and basis of diagnosis.
• Date of TB treatment initiation and regimen type.
• CBNAAT and Truenat Details - CBNAAT MTB Result, Rif Resistance, final interpretation and date reported.
• F line LPA and S line LPA Final interpretation.

Video: DRTB Treatment Register

Follow-up Register- This is a line list of all cases for whom face-to-face or telephonic follow-up was done to enquire about their condition based on current facility and follow-up date. This includes patients on treatment.
Post Treatment Follow-up Register- This is a line list of all cases for whom face-to-face or telephonic follow-up is to be done to enquire about their condition based on current facility and eligibility as per the Treatment outcome date. This includes patients, not on treatment who are eligible for Post Treatment follow-up.

Two new filters are introduced in this register:
Type of Follow-up Register- (Follow up, Post Treatment follow-up due).
Post-treatment interval period (All, 6 M, 12 M, 18 M, 24 M)– If Post Treatment follow-up is selected.

Description: This register provides detailed information on the status of follow-up visits:

• Date and Mode of follow-up ( Face to face at home or health facility or any other place and telephonic).
• Login id used-individual log-in who entered the data.
• Improvement in patient’s health condition or not.
• Reason of missed dosage.
• Patient weight and days of medicine left.
• Next follow-up visit date and type.
• Travel history/ Migratory status.
• Financial barriers and accessibility issues.

Video: Follow-Up Register

 This is a line list of all the private health facilities (active or inactive) registered in Nikshay and gives their beneficiary status if eligible for the incentive.

This register gives details about the private health facilities related to the following:

• Facility name and address.
• HF Code.
• Date when the facility was added.
• Contact person name and designation along with their contact details.
• Government registration number.
• Beneficiary status and Beneficiary ID.

Video: Private HF Register

This is a line list of all cases for whom comorbidity details are available in Nikshay based on current health facility and diagnosis date. 

This register gives comorbidity details of the patients pertaining to following:

• Health Facility details (Current & Diagnosing facility i.e., State/District/ TU/PHI).
• HIV status and date of HIV testing.
• Date of CPT Delivered, date of referral to ART and date of ART initiation.
• Diabetic status (RBS, FBS) and whether initiated on anti-diabetic treatment.
• Other comorbidity details - Tobacco and alcohol intake history and whether linked for cessation or deaddiction.

Video: Comorbidity Register

This is a line list of all beneficiaries with their status as per the current health facilities and notification date.

This report provides information pertaining to the following:

• Beneficiary details - ID, status and rejection reasons.
• Whether the user has foregone benefits for a particular patient.
• Bank account details - Bank account number, IFSC code, and validated name of the account holder as per PFMS, PFMS Beneficiary ID.
• The number of benefits-eligible and number of benefits paid via Nikshay/ External/Paid in kind.
• The total amount eligible and total amount paid via Nikshay/ External/Paid in kind.

Video: Beneficiary Register

This is a line list of all cases for whom CDST test was conducted and the final interpretation is available based on the testing facility. Separate register is available for various test types- CBNAAT, TRUNAAT MTB, TRUNAAT MTB-Rif, Culture, DST, F Line LPA and S Line LPA.

This register gives details about the tests and final interpretation:

• Test details - Test ID, Date of testing and reporting, Date of specimen collection.
• Reason for testing.
• Treatment status and date of treatment initiation.
• Number of HCP visits before diagnosis of current episode and duration of predominant symptom.
• Specimen details - Visual appearance of sputum, serial number, Rif resistance.
• Final interpretation of T.B.

Video: CDST Test Register

This is a list of all notified patients for whom any lab test was requested and test results are available during the selected period.

This register gives details about the tests and final interpretation:

• Diagnosing facility details - State/District/ TU/PHI.
• Details of Chest X-ray, microscopy, CBNAAT, Trunat, FLPA, SLPA, Culture and DST - Nikshay entry date, specimen collected date, date reported and final interpretation.

Video: Patient Lab Register

This is a list of all cases enrolled based on enrolment (registration) date and enrolment facility.

This register gives details about enrollment:

• Enrollment date.
• Health Facility (Enrollment, Diagnosing and current facility details ie.. State/District/ TU/PHI).
• Patient status and comorbidity status (HIV and Diabetes status).
• Demographic information.
• Treatment initiation date along with final outcome.
• Drug resistance.
• No. of Followup done.
• Diagnostic details ( Basis: test name and final interpretation, microbiological confirmation).
• Contact tracing details.

Video: Enrollment Register

Video: Deduplication Register

This report gives a detailed information on patients age-group-wise (above/below five/six years) for whom contact tracing visits are done. This now includes the ability to trace contacts of notified TB patients who have Latent TB.

This report enables user to view at a glance:
Health facility details (Diagnosing and current facility ie.. State/District/ TU/PHI).
Total household contacts (Age group wise : above/below five/six years) , number of contacts screened, number of cases with symptoms, number of evaluated, number of cases diagnosed and on treatment, number eligible for TPT, number provided TPT.

Note: As per the revised PMTPT guidelines, contacts <5 years are to be screened as of the release of the guidelines. However, it is understood that owing to the transition phase of the guidelines, most of the data with the field staff may be of <6 years. Accordingly, caution may be exercised in interpreting the report.

Video: Contact Tracing Register

Video: Adherence Register

Video: Switch Technology Register

This is a line list of confirmed DRTB cases on treatment based on current health facilities, along with follow-up of DRTB test details ( Smear and culture).

This register gives details about the final interpretation of tests based on the treatment start date and notification date:
Current facility details - State/District/ TU/PHI.
Final interpretation of culture at follow-up visits of DRTB patients and date reported.

Video: DRTB Follow Up Register

This gives a line list of health facilities - PHI/Private Practitioner, clinic(single), Hospital, Nursing Home (multi)/ Private Lab/ Private chemist along with their detailed information.

This register has gives the following details:

1. Health facility code and type
2. Status of Health Facility in terms of -

• DMC/ Truenat/CBNAAT status
• ICTC/FICTC/HIV Screening/Confirmation Facility
• CDST/LPA Lab
• Tobacco cessation clinic/ANC clinic/Nutritional Rehabilitation Center
• De-addiction centers/Prison/ART Centers
• Medical college/NUHM facility/District DRTB Center/Nodal DRTB/IRL/NGO
• Pediatric care facility
• Latitude and longitude details

Video: Health Facility Service Register

Video: DBT Summary

Video: DBT Beneficiary Status

Video: DBT Benefit Status

Video: DBT NPY

Video: DBT Transaction Summary

Video: Target Allocation

Video: JEET Excel Export

This gives a list of all transfer in/transfer out cases between health facilities based on notification date and transfer initiated date.

Description: This register gives details pertaining to the following-

1. Health facility details of both source and receiving state/district/TU/HF.
2. Transfer status - Accept, Reject, No action, Cancel.
3. Reason of transfer.
4. Enrollment date, diagnosis date and T.B treatment start date.

Video: Transfer Register

Video: Health Facility Notification Report

Video: Benefit Register

This is a line list of patients enrolled on MERM at any given point during their treatment duration. This register can be generated by selecting a given data range (monthly, quarterly, or yearly) for Public/Private or both health sectors and by Notification Date or Treatment Start Date.

This register gives details about the following data points relating to the MERM Devices:

• Patient ID
• Current Hierarchy Details
• Health Facility Type and Code
• Diagnosis Date
• Type of Patient
• Patient Status
• Patient Name
• Treatment Initiation Date
• Treatment End Date
• Outcome
• Type of Case
• MERM ID (This is an internal identification of the MERM module on the Nikshay database)
• IMEI Number (This is a unique 15-digit number which is used to identify the MERM module and appears in the dropdown list while allocating MERM to a patient)
• Last Seen (This refers to the most recent time that the MERM device has communicated with Nikshay – indicating that the module is in working condition)
• Last Opened (This refers to the most recent time that the MERM device has been opened by the patient to consume his medication. If Last Opened is available for a day, the calendar turns green to mark adherence)
• Last Battery (This refers to the last known battery level of the MERM module. If battery Level is below 3600 mV the module will have to be charged immediately)
• Allocated to Patient (Yes – indicates that the MERM module is still allocated to a patient: No – indicates that the MERM module is not currently allocated to the patient)
• Start Date (This indicates the date on which the patient has been allocated the MERM module for his treatment support)
• Stop Date (This indicates the date on which the MERM module has been de-allocated from the patient. Wherever Allocated to Patient is “No” a Stop Date should be available)
• Refill Alarm Enabled: If Yes – this indicates that the refill alarm option for the patient has been enabled.
• RT Hours – This refers to an internal ID to identify how often the MERM module connects with Nikshay to register Adherence. RT Hours for all devices should be 1 to ensure that it connects with Nikshay once every day.

Video: MERM Patient Register

This register gives details about the tests offered to patients along with final interpretation based on Health facility (Diagnostic and current) and Date range (Enrollment date, Notification date and Treatment start date) selected by user.

This register provides detailed information on the following:

• Demographic details
• Health Facility (Current, Diagnosing and testing facility details ie.. State/District/ TU/PHI)
• Patient status along with Diagnosis date and T.B Treatment start date
• Test details - Test ID, Test type, Date of test updated in Nikshay, Date of test reported, Reason for testing and test status
• Predominant symptoms reported and their duration
• Sample details: Date of specimen collection, Type of specimen for testing and visual appearance of sample

Video: Patient Centric Test Register

This register gives a list of all notified patients under the hierarchy for the selected period which shows the eligibility for private health facilities under the private provider scheme. It provides reasons on why a notification is not eligible for the benefit and, for eligible notifications, why the benefit has not been generated i.e. which prerequisite condition is not met.

This report provides information pertaining to the following:

• Health Facility (Diagnosing and Enrollment facility details ie. State/District/ TU/HF/HFID)
• Patient Duplicate status
• Private provider details - Current status, Current incentive Eligibility Status, Beneficiary Id and Current Bank Detail Status

Video: Private Provider Incentive Eligibility Register

Video: Service wise Summary Report

This register gives a list of patients whose refill is due based on Health facility ( Diagnostic and current) and Date type (Enrollment date, Notification date and Treatment start date ) selected by user.

This register provides information pertaining to the following:

• Demographic details.
• Health Facility (Current and Diagnosing facility details ie. State/District/ TU/PHI ).
• Refill Id, validation date and Chemist Id.
• Product type and name, Adult or pediatric, Weight band and no. of days.
• Diagnostic details (Date of diagnosis, basis of diagnosis) and treatment status.

Video: Refill Register

Video: Patient List F Line LPA Not Offered

Video: Patient List S Line LPA Not Offered

Video: F Line LPA Report

Video: S Line LPA Report

This register helps to track the turnaround time for DBT process Indicators for paid benefits via Nikshay. It gives the date of each benefit processing step and break-up of processing time (in days) taken to pay the benefits since their generation for the selected period & geography into four process steps : Maker processing time, Checker processing time, PFMS acknowledgement time, PFMS approval and credit time.

Description: This register provides information pertaining to the following:

• Month and year when benefit is credited
• Episode ID, Beneficiary ID and Benefit ID of the case
• Incentive number and amount generated under a particular scheme
• Benefit creation date, Maker processed date, Checker processed date, PFMS accepted date and benefit credited date.

Video: DBT TAT Indicator Register

Video: ACF Excel Report

Video: Co-morbidity report

Video: Contact Tracing Report

Video: Deduplication Report

This report gives a summary of ‘Drug Sensitive TB Diagnostic Services’, ‘Drug Resistant TB Diagnostic Services’, and ‘Treatment Services’. This report enables user to view at a glance the following:

1. Drug sensitive TB diagnostic services
   
   • Number of Presumptive TB cases tested in the Designated microscopy centre + CBNAAT/Truenat
   • Public and private sector wise: Total TB cases diagnosed (Both microbiologically confirmed & clinically diagnosed)
2. Nikshay Poshan Yojana (NPY)
   
   • Number of TB patients (Only DSTB) eligible for first instalment during the reporting month (Includes TB patients transferred in from other PHIs) (Public Sector)
3. Drug resistant TB diagnostic services
   
   • Number of TB patients tested for Rifampicin resistance (CBNAAT/ LPA/ TrueNat) among TB notified patients.
4. Treatment services
   
   • Number of TB notified patients initiated on 1st line (DSTB) treatment.
   • Number of TB notified patients initiated on 2nd line (DRTB) treatment.
   • Number of TB notified patients initiated on Bedaquiline treatment against initiated on 2nd line (DRTB) treatment.

Video: Monthly Summary Report

The Ni-kshay Online Portal under National Tuberculosis (TB) Elimination Program (NTEP) has a provision for generating TB treatment outcome reports which should be downloaded periodically to understand the TB treatment adherence and response to TB treatment provided to the patients.

Following are the steps to download and review the treatment outcome report from Ni-kshay.

Step 1: Open the Nikshay Reports page.

Step 2: Under Notification Reports, click Outcome Reports.

Step 3:  Select the date range, and type of patient (Public or Private) and click Get Data.

 

Figure: Outcome Report Display on Nikshay Online Portal

However, the outcome report depends on real-time data updating from the provider level. Any incomplete data updating may result in erroneous outcome reports. Hence, to get a correct outcome report, it is essential that all TB patients who have either completed their treatment, or have died or have discontinued treatment due to any reason (migrated, ADR, etc.), and their treatment outcome is filled in by Nikshay on a real-time basis.

Incomplete information in Nikshay can provide a wrong interpretation of the district’s treatment monitoring performance and overall treatment outcome. States and districts need to utilize this information for focused intervention for addressing challenges - comorbidities, delayed treatment initiation, treatment discontinuation due to any reason or treatment failure.

 

Video: Outcome Report

Resources

• Accessing and Downloading Reports in Nikshay.

Video: PMDT Report

Video: Treatment Status

Video: UDST Report

Video: Benefit Batch Register (DSC)

Video: DBT Signatory Register (DSC)

This is a line list of tests conducted in a given PHI’s Designated Microscopy Center. The test might have been conducted for any presumptive or confirmed TB patient which belongs to any hierarchy across India. This register can be generated by selecting a given date range (Microscopy tests-Date Reported) and based on the testing facility.

This register gives details about the tests and final interpretation:

1. Test ID, Lab serial number A and B.
2. Date reported.
3. Testing facility name and reason for testing.
4. Predominant symptoms reported and their duration.
5. Type of specimen for testing and visual appearance of sample.
6. Result of sample A/ B.
7. Final interpretation of test ( positive/negative).
8. TB treatment start date and Treatment type ( first line drugs

Video: DMC Register

Video: PFMS Agency Register (DSC)

This is a line list of Presumptive TB cases on the basis of enrolment (registration) date and enrollment facility in nikshay.

This register gives details about the following:

1. Demographic details.
2. Health Facility (Enrollment facility details ie.. State/District/ TU/PHI).
3. Key population.
4. HIV status.
5. Microscopy and CBNAAT report availability.

Video: Presumptive Case Register

Video: Patient List UDST Excel export (Not Offered)

Video: Accessing MERM report

Video: TB Notification Register

The different meetings conducted at the Tuberculosis Units (TU) are:

1) Patient-Provider Meetings: These meetings are organized by STS and conducted by the MO-TC for the patients.The purpose of these meetings are to counsel patients who are already on treatment or who are about to initiate treatment. This provides an opportunity for interaction between provider and patient. During these meetings patients are provided basic information about tuberculosis, cough hygiene, importance of completing treatment, possible adverse drug reactions and how to manage them, importance of follow up sputum examination and TB preventive treatment.

2) Community-level Meetings: These meetings are organized by the STS and conducted by the MO-TC for the patients, general public, community leaders/ people’s representative including Self-help Groups (SHGs), Non-Governmental Organisations (NGOs),  community volunteers, traditional healers, people practising other systems of medicine.These meetings are mainly conducted with the aim to increase the awareness levels in the population about TB, enhance referrals, improve adherence to TB treatment as well as to address the stigma , discrimination associated with the TB.

3) Sensitisation Meetings for Panchayati Raj Institutions (PRIs), NGOs, Private Providers (PPs): These meetings are organized by the District Public Private Mix (PPM) coordinator/ STS for elected representatives under the 3-tier Panchayati Raj System, State Government Health Systems (SGHS), NGOs, community leaders and community volunteers. The purpose of these meetings are to create awareness about the need for public action on TB and generate specific commitment from target audience on how they would support TB elimination efforts.

4) School-based meetings: These meetings are conducted by the STS at the schools and colleges for the teachers and students. The purpose of these meetings are to generate awareness amongst students and teachers of schools and colleges regarding tuberculosis and improving referrals for TB testing.

Resources

• Training Modules (5-9) for Programme Managers & Medical Officers, CTD, MoHFW, India, 2020.
• National Strategic Plan for Tuberculosis Elimination 2017–2025, MoHFW, India, 2017.

Assessment

Question	Answer 1	Answer 2	Answer 3	Answer 4	Correct answer	Correct explanation	Page id	Part of Pre-test	Part of Post-test
Who are the attendees in the Patient-Provider meetings?	MO-TC	Patient	STS	All of the above	4	MO-TC, patients and STS are the attendees in the Patient-Provider meetings.		Yes	Yes

Review meetings are conducted at each Tuberculosis Units (TU) on a monthly basis in order to review the activities and address if any issues. The MO-TC is responsible for conducting these meetings 

The other participants are: Senior Treatment Supervisors (STS),  TB Health Visitor (TBHV), Senior TB laboratory Supervisor (STLS), General Health system staff and Treatment supporters.

Activities reviewed at TU level

The various activities reviewed during the TU review meetings are Case finding, Sputum smear examinations conducted at all the Designated Microscopy Centres(DMCs) of the sub-district,, Supervisory visits conducted by STS and STLS, Categorization of diagnosed patients based on the treatment regime, Treatment outcomes of cohort-wise patients who were expected to complete the treatment during the period, Information, Education, Communication (IEC) activities conducted, Status of the Ni-kshay patient registrations, Direct Beneficiary Transfer (DBT) linkages and Ni-kshay Aushadhi Updation, Drug supply and other logistics to all peripheral health institutions (PHIs), Returned drug stocks if any and all other Programmatic performance indicators.

Role of STS and STLS in supporting MO-TC to review the performance of the TU

The STLS must:

• Ensure all notified TB patients in the block are tested and results have been obtained.

• Maintain a list of all follow up smear positive patients separately and submit to the  MOTC before the review.

• Complete Sputum collection for all presumptive DR TB patient identified.

• Visit all DMCs during the month to identify if any concerns and bring them to the notice of the MOTC.

• Update all reports related to diagnosis and follow up examinations on Ni-kshay.

 

The STS must: 

• Update the list of new and old patients on treatment for the reviewing month.

• Correctly classify patients as per their TB treatment regimen and record all related events in Ni-kshay. 

• Maintain an up-to-date list of all treatment interrupters and lost to follow up patients, with the duration of interruption and reasons that lead to the same.

• Prepare a report of the patient-wise visits conducted during the period.

• Prepare a report on performance of the treatment supporters.

• Prepare a list of all pending DBT linkages and report the reasons for backlogs.

• Supervise and report all the community engagement activities conducted during the reviewing month and update on planned activities.

• Prepare report on all drug issue and returns during the month.

• Report on involvement in private sector engagement activities conduced (if any) during the period.

With support from the STS and STLS the MOTC can review the performance and shall further conduct home visits for the patients in order to address the issues.

Resource

• TRAINING MODULES (5-9) FOR PROGRAMME MANAGERS & MEDICAL OFFICERS, CTD, MoHFW, India,2020.
• NATIONAL STRATEGIC PLAN FOR TUBERCULOSIS ELIMINATION 2017–2025, MoHFW, India, 2017

 

Assessment

Question	Answer 1	Answer 2	Answer 3	Answer 4	Correct answer	Correct explanation	Page id	Part of Pre-test	Part of Post-test
Who is responsible for conducting the review meeting at the TU level?	State TB Officer	District TB Officer	Medical Officer-TB Control (MO-TC)	Patient	3	Medical Officer-TB Control (MO-TC) is responsible for conducting the review meetings at the TU level.		Yes	Yes