DR-TB HIV Coordinator: Monitoring and Review

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.	​

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.

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 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.

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.

Alongside regular monitoring through Ni-kshay application, National TB Elimination Programme (NTEP) also recommends conducting periodic meetings at various levels across the country to review the Programmatic Management of Drug-resistant Tuberculosis (PMDT).

These meetings help the programme through discussions and reviews of various aspects such as updates on guidelines, performance tracking, and taking corrective actions in order to address the implementation challenges wherever required.

PMDT Review Mechanism at Various Levels

Level	Meeting	Chair	Frequency	Participants/ Committees
National level	Biannual National State TB Officer (STO) - Consultants’ meeting	Deputy Director General (DDG)- TB	Annual	STOs & state PMDT coordinators in the region
	Regional PMDT review meeting			World Health Organisation (WHO) NTEP Regional Team Leads (RTLs) & consultants
State-level	State PMDT committee meeting	Principal Secretary (Health)/ Managing Director (MD) National Health Mission (NHM)	Quarterly	Members of state PMDT committee
	District TB Officers (DTO) quarterly review meeting	MD NHM/ STO	Quarterly	Concerned NHM and State TB Cell (STC) officials, State TB Training and Demonstration Centre (STDC), Intermediate Reference Laboratory (IRL), Culture and Drug Susceptibility Testing (C&DST) lab and DTOs
	Nodal DR-TB Centre (NDR-TBC) site coordination meeting	Nodal officer/ Senior medical officer – NDR-TBC	Quarterly (1st week of each quarter)	Concerned NDR-TBC staff & all senior DR-TB TB-HIV supervisors of the districts linked to NDR-TBC
District-level	NTEP review meeting of the Medical Officer – Tuberculosis Units (MO-TU)	District magistrate/ Chief medical officer/ DTO	Monthly	District programme managers, MO-TU, medical college nodal officers, DR-TB nodal officers, In-charge/ microbiologists C&DST lab, Senior Treatment Supervisor (STS), Senior Tuberculosis Laboratory Supervisor (STLS), Tuberculosis Health Visitor (TBHV), Laboratory Technician (LT), General Health System (GHS) staff
Block Level	NTEP performance review	MO-TU/ Block medical officer	Monthly	Block medical officer/ MO-TU, TU staff (STS, TBHV, STLS), Health Facility (HF) staff
Health Facility (HF) level	NTEP performance review	MO-HF	Monthly	STS, TBHV, STLS, HF staff including Community Health Officer (CHO) & team

 

Following are the key indicators* reviewed during a PMDT review:

• Coverage of Universal Drug Susceptibility Testing (UDST)
• Profile of resistance pattern reported for patients during that period
• Turn-around time for lab activates
• DR-TB notification rate
• DR-TB treatment initiation rate within 7 days of diagnosis
• DR Treatment adherence rate (both treatment interruption and lost to follow-up (LTFU))
• Counselling and rate of retrieval or treatment interrupting/ LTFU patients
• Interim smear/ culture conversion rate as per various regimen
• Resolution of serious adverse events
• Treatment outcomes
• TB Preventive Treatment (TPT) Coverage and completion rate
• Direct Beneficiary Transfer (DBT) coverage rate

(*All indicators are disaggregated and reviewed across age, gender and type of drug resistance.)

 

Resources

• Guidelines on Programmatic Management of Drug-resistant TB (PMDT) in India, CTD, MoHFW, GoI, 2021.

 

Assessment

Question	Answer 1	Answer 2	Answer 3	Answer 4	Correct answer	Correct explanation	Page id	Part of Pre-test	Part of Post-test
At what level under the NTEP are the Regional PMDT review meetings conducted?	National	State	District	Block	1	Regional PMDT review meetings are conducted at the national level and are attended by the World Health Organisation (WHO) NTEP Regional Team Leads (RTLs) & consultants.		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