Fighting TB in India: CARE's IMPACT

What is IMPACT?
IMPACT stands for The Initiative to Manage People Centered Alliances in Control of Tuberculosis (TB). It was begun in 2009 by CARE India in close partnership with India’s Revised National Tuberculosis Control Plan (RNTCP) and will wrap-up in 2013; it is being implemented in five districts in West Bengal, India. The main goal of IMPACT is to “decrease morbidity and mortality caused by tuberculosis, multidrug resistant TB (MDR-TB), and TB-HIV co-infection in the state of West Bengal, India.” CARE India has much experience and success in fighting TB. It implemented a community based DOTS program from 2001 to 2005 that served 10 districts in West Bengal. “The project successfully demonstrated how involvement of community volunteers, raising community awareness, and identifying and creating community based DOTS providers can substantially increase case detection, treatment completion and cure rates, and reduce default rates, especially in poorly performing RNTCP pockets” (CII 2008).

The Need for CARE

India is home to more than 900 million people who live on less than $2 per day. Although the country has made great strides in development lately, some health indicators are lagging behind. For example, 46% of children under three years old are malnourished, and the average life expectancy is 64 years (DFID 2007). Tuberculosis is a stubborn disease that has been plaguing India for centuries. When IMPACT began in 2008, one fifth of all new TB cases in the world occurred in India (WHO 2006). Tuberculosis preys on the weak and the strong alike; over 70% of cases occur in people aged 15-54 (ORG 2007). TB can cause economic devastation for families if the primary income generator becomes infected. In West Bengal, home to around 8.6 million people, there were an estimated 64,076 cases of TB in 2008. While Case Detection Rates and Cure Rates meet WHO targets of 70% and 85%, respectively, there are areas where the rates are much lower (GoWB 2007). Over half of local Tuberculosis Units (TUs) do not meet national targets (GoWB 2006). Treatment default rate remains a problem; defaulting can be deadly for some patients, and rates were 15% in West Bengal in 2008 (GoI 2007).

Two other main problems in West Bengal are TB-HIV co-infection and MDR-TB. Although the HIV prevalence is relatively small in West Bengal, many TB patients who are suspected to have HIV are slipping through the cracks of the complicated health system and are not getting tested (Uplekar 1998). MDR-TB is much more difficult to treat, requiring six months of directly observed treatment and rest, followed by up to one and a half years of taking drugs that are toxic and cause serious side effects. In India, up to 3% of initial TB cases and up to 17% of cases among people who have been treated for TB before are MDR (GoI 2007). Although TB treatment is free in India through the RNTCP, barriers to care exist, including the cost of accessing care (transportation, hospital stays, private practitioners,) stigma, and drug side effects.

IMPACT: Strategy and Actiontriangulating_information_in_Malda.JPG

IMPACT operates under three strategic objectives to accomplish its goal of decreasing TB morbidity and mortality. They are as follows:

  1. 1. Intensify and expand community based DOTS, especially in poor performing TUs.
  2. 2. Decrease the prevalence of MDR-TB by decreasing treatment default rate and increasing treatment completion rate among re-treatment patients and MDR-TB patients.
  3. 3. Strengthen TB-HIV coordination at the state and district level in order to improve referral system and ensure testing and treatment for HIV-TB co-infected individuals.

The following are actions IMPACT has taken in order to achieve its strategic objectives:

  • Partnered with association of non-qualified private practitioners (NQPPs) to train them on TB symptoms and encourage them to refer suspects to RNTCP labs for testing.
  • Identified and trained 60 NQPPs as DOTS providers
  • Performed doer/non-doer surveys
  • Linked patients to welfare schemes by sensitizing government officials at various levels
  • Financially supported transportation for MDR TB patients to testing centers
  • Counseled 272 MDR-TB patients and family members
  • Held 1,300 patient provider meetings to decrease default rate
  • Held meetings with TB-HIV coordinating committees at district and state levels
  • Sensitized HIV networks regarding TB via partnership with Bengal Network of Positive People
  • Established 27 sputum collection centers
  • Built capacity of other NGOs for referring TB suspects

After only two years of implementation, the TUs selected because of their poor performance have shown a 4% increase in Case Notification Rate. Most other indicators, including the default rate and treatment success rate have remained relatively constant for all the TUs. However, there has been a positive response to IMPACT’s activities from the government, other NGOs, NQPPs, community groups, and TB patients. This suggests that final results will show an increase in numerical TB indicators. For example, the government has institutionalized IMPACT’s idea of linking TB patients to welfare schemes. Also, self-help groups in IMPACT communities have good knowledge of TB symptoms and positive attitudes toward the RNTCP and IMPACT. Additionally, NQPPs have referred over 4,627 TB suspects, 627 of whom were diagnosed with TB. More results and key lessons learned will be reported in the final evaluation in 2013. Until then, IMPACT will continue striving to improve the lives of TB patients and prevent the spread of TB through strong partnerships and community based strategies.

Department for International Development.
Accessed 2007.

Government of India. (2007). Tuberculosis in India.

Government of West Bengal, MoHFW. (2007). West Bengal State TB Cell.

ORG Center for Social Research. (2007). Social assessment study for RNTCP. India.

World Health Organization. (2006). Global TB Report.

Unpublished. Third quarter data TB data. (2006). Government of West Bengal, Department of Health.

Uplekar, M., Juvekar, S., Morankar, S., Rangan, S., Nunn, P. (1998). Tuberculosis patients and
practitioners in private clinics in India. Int J Tuberc Lung Dis. 2(4):324-329.

*This document was adapted from CII’s IMPACT proposal (2008) and Midterm evaluation (2011).