IEC Baseline Document For RNTCP

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IEC –BASELINE DOCUMENT
CENTRAL TB DIVISION
August, 2007
Report compilation: New Concept Information

Systems, New Delhi
Baseline IEC document-RNTCP II
CTD
Contents
Executive Summary 1
Chapter I
Introduction 5
Chapter 2
Awareness among target
Segments 10
Chapter 3
Institutional Capacity 25
Chapter 4
Conclusions & recommendations 48
Annex
IEC Audit Questionnaire 51
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Executive Summary
The RNTCP is an application in India of the WHO-recommended Directly

Observed Treatment, Short Course (DOTS) strategy to control TB with the
objective of curing at least 85 per cent of new sputum positive TB patients
and detecting at least 70 per cent of such patients.
The RNTCP strategy aims to ensure political and administrative commitment

at all levels; diagnosis through quality sputum microscopy of patients
attending peripheral health facilities; uninterrupted supply of Short-Course
Chemotherapy drugs, which are given in patient-wise boxes; direct
observation of treatment through involvement of peripheral health
functionaries, NGOs and community volunteers, and systematic monitoring,
evaluation, and supervision at all levels.
The RNTCP is in its second phase now and is a step towards achieving the
TB-related Millennium Development Goal (MDG) targets. In order to ensure
equitable quality services, RNTCP II emphasises inter-sectoral collaboration,
involvement of medical colleges and the implementation of a revised IEC
strategy.
The IEC strategy mainly focuses on awareness generation, advocacy and

patient-provider communication and counselling.
The target groups are three clear segments:

1. Patients and their families;
2. Opinion Leaders; and
3. Health Providers (Public & Private).
Other than the above target groups, advocacy activities are seen as being
essential for doctors, other professionals and their associations along with
senior government officials, and parliamentarians and political
representatives.
This Baseline IEC document summarises information about the health

communication initiatives and its impact/ effectiveness from the different
studies conducted over a period of time in RNTCP. These are three
Knowledge Attitude and Practices (KAP) studies - baseline mid line and End
line studies of RNTCP Phase I, two studies on accessibility and utilization of
RNTCP by the marginalised section (SC/ST and women) conducted during
RNTCP Phase I, and social assessment & institutional assessment studies
conducted prior to the launch of RNTCP II. Besides these there is useful
information about the awareness level and also about patient satisfaction
level that is captured through interviews during internal evaluations. Data
from 130 odd internal evaluations (between Jan 2006- March 2007) has
been drawn for this document. The expenditure statements compiled at the
national levels from the statement of accounts submitted by the state for
the financial year 2006-2007 has also been summarised to see the trends
of expenditure on IEC component in the states and districts.
The other very important information provided in this report is the findings
from the IEC audit questionnaire. The IEC audit questionnaire was
developed after a series of deliberations and consultations with the partners
and the Programme Managers in the field. The main objective of
administering this questionnaire was to take stock of the current capacity in
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order to fulfill the objective: increase in state and district level capacity to
plan and execute IEC activities.
This report is a compilation of results gleaned from the above reports, as

well as monitoring visits and internal evaluations based on an IEC audit
conducted by the Central TB Division. This report will serve as baseline
information and to monitor three outcome indicators which are specifically
relevant to Advocacy and IEC. These are:
Increase in the level of awareness about TB diagnosis and DOTS

treatment amongst practitioners
Increase in target groups being reached with information that DOTS is
the correct treatment, and is available free in patient wise boxes
Increase in the state and district level capacity to plan and execute IEC
activities.
The main findings from the compilation of the various studies, and audit and
internal evaluations are as follows:
1. While general awareness about TB among rural communities, opinion

leaders, and slum and urban communities as well as among health service
providers is high, the awareness among marginalised tribal communities is
comparatively low.
2. Awareness that sputum test is the most reliable method for diagnosis has
increased to about 23 per cent among communities. Among opinion leaders,
42 per cent still feel that X-ray is the main tool for diagnosis. The health
care providers feel that patients on many occasions do not come back for
follow-up sputum examination for reassessment, because of fear that
relatives/friends might stigmatise them because of their previous history
of TB.
3. While there is high awareness regarding “DOTS being the surest way to
cure” but there is lower awareness regarding anti-TB drugs being available
free and in patient-wise boxes.
4. Regarding duration of treatment, there is incomplete understanding among

disadvantaged and tribal communities and even in the case of opinion
leaders.
5. Mass media has played an important role in urban areas for spreading
awareness about DOTS.
6. Stigma based on deep rooted perceptions and gender issues pertaining to

the disease remain an issue. While most of the reports captured responses
of social acceptance to this question, further probing has documented deep
rooted discrimination in families and communities.
7. It has been seen that people do access government facilities and services
for both diagnosis and treatment. However, one of the reasons cited for
accessing private centres was the long distances to government centres.
Distances involved and time spent in accessing services is a barrier to
utilisation of services for potential patients. This is an issue in urban slums
and tribal regions.
8. Applying the lessons from the collaborations with the private sector, the CTD
had developed guidelines for the involvement of private practitioners in the
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TB programme. The guidelines provide scope for different schemes through
which the private sector can be involved. This had resulted in many PPs
coming forward and getting involved. The End line KAP study showed that a
little over half of the public providers were aware that they could involve PPs
as part of the scheme.
9. In terms of institutional capacities, it is a very positive step that almost all

large and medium states have IEC Officers. However, the fact that two
critical states (both from a population size point of view as overall low
development indicators perspective) Bihar and Uttar Pradesh do not have
IEC Officers.
10. Almost all IEC officers have undergone at least one training (training for
IEC Officers for planning and implementing IEC activities) organised by
Central TB Division. However, many of the state TB cells have expressed
lack of or a low level of confidence in planning and implementing IEC
programmes. Most of the states have expressed low level of confidence for
organizing IEC activities for general public, political and administrative
officials, as well as for private practitioners or patient level counselling.
11. It has been observed that the IEC capacity audit has been a very positive
step, in terms of responses as also the feedback from the regular
monitoring visits and internal evaluation. This has also reflected that a
beginning has also been made with respect to the appointment of
Communication Facilitators.
Several recommendations emerge from the studies conducted. These may

be classified as those that need to be addressed at State/district level and
those that need to be addressed at Central level.
State/districts need to pay further attention to increasing level of awareness

among beneficiaries, specifically with reference to:
Treatment and its duration

Availability of free drugs in patient-wise boxes
Importance of taking medicines under the direct observation of DOT
provider
Sustaining communication networks to widen the reach of information to
raise public awareness among marginalised and difficult to reach tribal
communities.
With regard to health care providers, the state/districts would need to pay
attention to the following:
Consistent technical information would need to be provided to health

service providers in the private sector.
Level of awareness about TB diagnosis and treatment as per RNTCP needs
to be raised
Advocacy for enhancing willingness to participate in RNTCP
Advocacy with private practitioners to be strengthened so that correct and
precise messages are transmitted to the patients who use them as first
point of service; advocacy with public providers is needed in order to
encourage them to enlist the support of PPs for the scheme.
Most of the states have designated IEC personnel, but the two states of
Uttar Pradesh and Bihar must appoint IEC officers and place this as top
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priority action; in the case of Uttar Pradesh more than one IEC officer may
be considered because of the sheer size of the state.
Similarly with respect to the appointment of Communication Facilitators

(CFs) which is a new initiative, the process has been completed by 14 out of
27 states eligible to appoint CFs. Workable arrangements are being
developed in the states indicating need for regular training, updating and
interaction between CFs, IEC officers DTOs and STOs.
Logistic support for the field visits by the IEC Officers is an issue that has
been pointed out by many state IEC officers. This requires intervention of
the state TB Officers and calls for better micro level planning in the districts.
Over all there is need for intensive media campaigns in order to

complement IEC activities that are organized by the states and districts. It
is reported that media campaigns have not only facilitated interaction with
the target audiences but also enhanced effective recall of messages.
At Central Level while the process of building the capacity of the states to
plan and implement IEC activities has been initiated, the following areas
need strengthening:
Messages regarding provision of drugs in patient-wise boxes also need to

be promoted in the media campaigns
From the IEC audit questionnaire it appears that a number of states are not
very confident of planning and executing ACSM activities indicating the need
for capacity building of the states at regular intervals. The CFs and State TB
cells must in turn plan for similar inputs at district level.
IEC audit also highlights the need for standardised training. The
identification of the required number of CFs, their training and positioning
needs to be taken on an urgent footing. In each region, workshops would
then need to be organised with focus on:
( IEC planning and budgeting skills;

( ACSM concept and techniques; and
( Monitoring on the basis of result framework.
State TB Officers feel confident to conduct and undertake IEC activities in

the states whereas expenditure on this component does not match
correspondingly. Expenditure across districts varies even within the well
performing states, suggesting the need for training of the Programme
Managers in the districts.
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CHAPTER I
Introduction
Background
Every year 1.8 million people in India develop tuberculosis (TB) and nearly
370,000 die from it every year. This amounts to a staggering two people
dying every three minutes. The emergence of HIV-TB co-infection and multi
drug resistant tuberculosis has increased the severity and magnitude of this
TB epidemic. Tuberculosis has devastating social costs as well – data
suggests that each year more than 300,000 children are forced to leave
school because their parents have TB, and more than 100,000 women with
TB are rejected by their families.
This continued burden of disease is particularly tragic because TB is nearly

100 per cent curable. Untreated patients can infect 10-15 persons each year
and poorly treated patients develop drug resistance and potentially
incurable TB.
Revised National Tuberculosis Control Programme (RNTCP)
The RNTCP in India is an application of the WHO-recommended-Directly

Observed Treatment, Short Course (DOTS) strategy to control TB with the
objective of curing at least 85 per cent of new sputum positive TB patients
and detecting at least 70 per cent of such patients. Large scale
implementation of the RNTCP began in 1997.
The components of the strategy to control the spread of TB are:
1. Political and administrative commitment at all levels

2. Diagnosis through quality sputum microscopy of patients attending
peripheral health facilities
3. Uninterrupted supply of Short-Course Chemotherapy drugs, which is
given in patient-wise boxes
4. Direct observation of treatment through the involvement of peripheral
health functionaries, NGOs and community volunteers, and
5. Systematic monitoring, evaluation, and supervision at all levels.
Since March 2006, The Revised National TB Control Programme is being

implemented in 100 per cent districts of the country covering the entire
1114 million population of the country.
RNTCP Phase II
The second phase of the RNTCP aims to consolidate, maintain and further
improve the achievements of the first phase. Phase II of the RNTCP is a
step towards achieving the TB-related Millennium Development Goal (MDG)
targets. Directly Observed Treatment Short Course - ‘DOTS’ - remains the
core strategy.
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Goal and Objectives of RNTCP Phase II
Goal:
The goal of TB Control Programme is to decrease mortality and morbidity
due to TB and cut transmission of infection until TB ceases to be a major
public health problem in India.
Objectives:
1. To achieve and maintain a case detection of at least 70 per cent of new
sputum positive TB patients.
2. To achieve and maintain a cure rate of at least 85per cent in such
patients; RNTCP II is expected to maintain at least 70 per cent case
detection rate of new smear positives and maintain a cure rate of at
least 85 per cent.
The TB Control Programme aims to further increase access to services for

marginalised groups in hard-to-reach areas through continuation of all
activities of Phase I with intensive monitoring, supervision and evaluation.
To provide standardised, good-quality service in a patient-friendly
environment, the Programme aims to further strengthen inter-sectoral
collaboration, by engaging medical colleges and by conducting need-based,
focused and people-centric Information, Education and Communication
(IEC) activities.
New initiatives have been introduced in Phase II with the aim of providing
standardised, good quality treatment and diagnostic services to all TB
patients in a patient-friendly environment irrespective of the health care
facility from where they seek treatment. Involvement of other sectors in the
Programme is aimed at widening the reach of RNTCP services. In addition,
norms have been relaxed to address the needs of patients in remote areas.
RNTCP gives special attention to the following activities to ensure equitable

service delivery:
a. Inter-sectoral collaboration
b. Involvement of medical colleges
c. IEC activities: Revised IEC strategy for RNTCP II has been developed and
disseminated. The emphasis is now on locally appropriate; need based
planning & implementation of IEC activities. IEC action plans prepared
by the district are monitored and reviewed by the states/centres.
Communication facilitators have been provided to support the districts in
planning and executing IEC activities. This is an additional support to the
districts under RNTCP.
d. Tribal action plan to improve access to tribal and other marginalised
groups.
IEC (Information, Education and Communication) Strategy for

RNTCP
Advocacy and communication is a central and integral part of the Phase II

RNTCP. Communication plans are directed towards scaling up the current
level of communication activities through good mass media campaigns to
creating a supportive and enabling environment for grassroots level
participatory processes and community empowerment. The Communication
strategy includes an appropriate mix of mass media interventions and
community based processes to facilitate rapid enhancement of awareness in
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the short term and at the same time also ensuring sustainable and broader
social commitment in the long term.
With the Tuberculosis Control Programme now operational across India,

RNTCP is extending the reach and effectiveness of communication through
an IEC strategy that ensures that:
1. IEC is a long term commitment wherein IEC is both process and product
oriented.
2. IEC activities are based on analysis of local needs and specific situations
to ensure contextual relevance. For example, opportunities for
interactive communication, such as engaging cured patients to convince
and support others, group meetings to discuss all aspects of TB control,
including the social aspects are effectively incorporated in the local
plans.
3. Most of the IEC activities are decentralised with the centre providing
leadership and capacity building support.
4. Encouragement is provided for implementing locally relevant adaptation
and innovation to reach all possible groups with the most appropriate
communication tools.
5. Care is taken to address social issues related to TB such as stigma and
gender. Special communication initiatives are also being taken to
address the needs of the groups and ‘hard to reach populations’.
The core objectives and focus of IEC in Phase II of the programme are:
1. To raise awareness of:

the public (including special communities) about TB and RNTCP services
practitioners to enable improved diagnosis and treatment; or become
DOTS providers
2. Advocacy to develop political, administrative and community-level

commitment to TB control in India.
3. Improved patient-provider communication and counselling
to ensure patient compliance with treatment regimen;

to enhance patient-friendly services; and
To encourage successfully cured patients and their families to become
peer-educators of the programme.
The target groups are three clear segments. These are:
Patients, & their families

This segment forms the largest group among the segments and also needs
to be considered in terms of their wide diversity, socio-economic status,
language, geographic spread and cultural milieu.
Opinion Leaders
Opinion leaders, both formal and non-formal play an important role as
influencers within communities and with individual families. Informal and
formal leaders are targeted within this segment.
Health Providers (Public & Private)

Sensitisation of these groups, along with involvement of and cooption of
private providers is an important element of the strategy.
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Other than the above target groups, advocacy activities are seen as being
essential for doctors, other professionals and their associations along with
senior government officials, and parliamentarians/political representatives.
A number of initiatives have been taken in RNTCP to address health

communication components of the programme. The programme has also
conducted studies to document the accessibility and utilisation of services
by the different sections of target groups. Over a period of time various
studies have been conducted in order to assess the impact of media
activities.
Information about the health communication initiatives and its impact/

effectiveness is available in three different studies conducted over the past
few years. For the purpose of making these findings available for easy
reference, all information related to communication was collated in one
document and additional information was collected from the states through
a questionnaire (IEC audit questionnaire) to indicate their capacity to plan
and implement IEC activities in the states and districts. Information has also
been gathered on different IEC activities through an internal evaluation
study comprising of Patient Interview forms which capture very important
information about awareness levels, knowledge of duration of treatment,
patient satisfaction levels and sources of information about TB.
This Baseline IEC document is designed to give comprehensive information

from the following sources:
1. Three KAP studies
( Baseline study was carried out in November 2002 to understand the
communication needs based on the knowledge level, behaviour patterns
and habits of the target audience.
( A Mid term study was conducted in November 2004 to gauge the

change in KAP using the same indicators.
( The End line assessment followed in May 2005 to review the

performance of the programme.
2. The Social Assessment study provides the basis for general awareness
among the respondent categories to cover socio-economic and literacy
levels of the respondents.
3. Data from the Internal Evaluations- Internal evaluation by the state and
central team has been conducted for about 160 districts during
2006-2007.
4. IEC Audit Questionnaire from almost all the states and UTs – which
capture information about the capacity of states to plan and implement
IEC activities. This was done in the month of March 2007.
The Three KAP studies conducted over a period of time provides valuable
information. However, the figures shown in these three studies should be
taken in reference to the context of social and economic differences. The
End line study made additions with respect to some indicators and this
assisted in gathering more relevant information that contributed to the
Communication strategy for RNTCP II.
Of the three KAP studies conducted, the Baseline and End line are quite
exhaustive studies. Nine states were selected from designated zones in the
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country and classified into categories on the basis of districts covered by the
RNTCP for monitoring and evaluating impact of IEC. Since RNTCP is aimed
significantly towards the rural and urban poor, rural clusters and urban
slums within each of the selected districts were included. For the End line
study nine STOs, eight IEC officers, 28 DTOs and 25 BEEs (total of 70)
were also included. Approximately 18 districts, seven district headquarters
(only for End line) and 1440 households, 180 opinion leaders and 216
health care providers were covered in the nine sampled states in both
baseline and End line surveys.
Four specific respondent categories were covered in this IEC impact

assessment.
Households/communities
1. Rural & Urban poor and tribals (as marginalized communities) (Social
Assessment study matrix)
2. Opinion leaders include Pradhans, ANMs, AWWs, Mahila Mandals, NGOs,
Religious Leaders and Teachers
3. Health service providers including private, public and traditional health
providers
The IEC capacity audit administered in March 2007 built was on the
experience of the above studies and gathered information on other
important aspects for undertaking IEC activities in the states and districts.
The purpose of the IEC audit conducted was to get baseline information
about the capacity of the states to plan and execute the IEC component of
the programme.
The IEC audit covered the following:
( IEC staffing and positioning, their academic background and skills

( Capacity at state and district levels to plan, organise and manage IEC
activities
( Support provided from centre to state and from state to district
Every quarter, each state conducted internal evaluations of two of their

districts (and in the case of one state for two districts in that state per
month) along with the team from the centre. The internal evaluations are a
part of an intensive supervision and monitoring strategy. In each such
internal evaluation about 40 patients are interviewed, and information
regarding patient’s knowledge and awareness regarding TB & DOTS, and on
the importance of completion of treatment is collected.
This baseline IEC document is a compilation of results from all the above
mentioned reports and would assist the RNTCP II in monitoring the three
outcome indicators. The three outcome indicators relevant to Advocacy and
IEC are:
Increase in the level of awareness about TB diagnosis and DOTS

treatment amongst practitioners
Increase in target groups being reached with information that DOTS is
the correct treatment, and available free in patient wise boxes
Increase in the state and district level capacity to plan and execute IEC
activities
The plan is to repeat this exercise at Mid term and End line to see the
increase in trends as regards the above indicators.
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CHAPTER 2
Knowledge and Awareness Levels among
Different Target Groups
The Revised National TB Control Programme has a well defined
communication strategy to increase the level of awareness about TB, its
diagnosis and treatment among patients and communities, to ensure
standard treatment by involving health care providers from other sectors,
and for ensuring support and resources through the involvement of
opinion leaders.
In order to assess the level of awareness about TB and its treatment, and
also to understand the attitudes and practices in relation to TB, studies have
been conducted during RNTCP I (refer page 10 for details of three KAP
studies, as well as the studies related to accessibility and utilisation,
conducted between the years 2002-2005) which have addressed
these issues
Data from the Internal Evaluations also indicate the level of awareness
about TB, its treatment, and duration of treatment and to some extent also
shows the level of satisfaction with TB care facilities.
This chapter is based on the findings from above studies and also sees the
trends or changes in the level of awareness as documented in the KAP and
other studies. These studies document that there has been an increase in
the level of awareness among different target groups and there has been a
promising change in attitudes and practices.
The three KAP studies, conducted by Centre for Media Studies in

collaboration with the media agency – R K Swamy BBDO Pvt. Ltd, were
carried out to highlight the impact that the media campaigns had had on all
communities during RNTCP Phase I.
Studies of accessibility and utilisation of RNTCP services by the marginalised

sections of society were carried out to see the pattern of utilisation of
RNTCP services by the SC/ST communities and also by women.
The Social Assessment study was done before RNTCP II and has provided
qualitative and useful information to developing the Project Implementation
Plan for RNTCP II.
Main findings from these studies have been summarised according to the
three target groups identified in the communication strategy. It focuses on
level of awareness, attitudes and practices among each target groups as
documented in the above studies.
CTD
I – Findings about level of Awareness :
General awareness about TB being a common disease
Among the General Public: The baseline KAP study and the study on
accessibility and utilisation of RNTCP by the marginalised indicate that
spontaneous recall of TB was not that high. Over the past two years, there
has been an increase in awareness about TB. For example, the percentage
of people who had heard of TB (for example in Tamil Nadu awareness was
up from 7% to 13% and in Gujarat from 4% to 21%) had gone up between
the Baseline and End-line study periods.
(Source: Graph 3.1 and table 3.1 End-Line Survey pp 15A)
Among Urban Slum Dwellers/Migrant Workers/Industrial Workers:

The Social Assessment study shows that awareness about general health
and TB was higher as were symptoms that warrant testing, diagnosis and
treatment. Patients were aware what disease they were being treated for.
There was a high awareness that persistent cough for over 3-weeks was the
main symptom of TB. Communities have also mentioned malnourishment,
congested and unhygienic living conditions and alcohol consumption as
causes of the disease. Overall the study shows that a large number among
the marginalized communities is aware that TB is completely curable.
Among Tribal Populations: In the Social Assessment studies conducted,

tribal communities especially in more remote areas, had low awareness of
TB as a disease. Awareness therefore was low about symptoms, diagnosis
and treatment. Among the tribal populations, the main sources of
information were friends, relatives and health workers.
Tribal women believed that TB was prevalent among their communities

because they were malnourished. Awareness about symptoms of the
disease was low among the tribal populations. Those being treated for TB
felt it was caused due to excess work, coughing, sharing food etc.
(Source Social Assessment Study)
Among Opinion Leaders: Overall, the spontaneous recall (without

prompting, i.e. first thing that comes to the mind of the respondent) of TB
among opinion leaders has gone up since the Baseline study in all the states
sampled, with the highest percentages being in Tamil Nadu, Maharashtra
and Gujarat. Overall percentages are between 14-25 per cent in the states
of Uttar Pradesh, Himachal Pradesh, Meghalaya and W. Bengal.
Among Health Service Providers: Baseline KAP study has questions that
would indicate what symptoms health care providers look for when they
come across TB patients. Most of the government doctors who work for
RNTCP are given 12 days modular training, whereas among private care
providers, knowledge about RNTCP would depend on their own interest in
the programme, sensitization meetings and interaction with RNTCP staff and
the media campaign by the programme.
In the Baseline study in 2002 a question was asked as to whether health

service providers anytime looked for cough for three weeks rather than
asking about “coughing of blood” to identify a potential patient. The
documentation shows that though the providers identified "coughing of
blood" as one of the symptoms, on further probing they did indicate that
they do not wait for this symptom to confirm diagnosis. Encouraging finding
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is that more and more of the health service providers are sensitive about
cough for three weeks, rather than any other symptom.
There is a general perception among the health care providers that TB is not
a very common disease. In the baseline study only 35 per cent of health
care providers felt that TB is a common disease and in the End line study 44
per cent perceived that it was not a common disease. (This may suggest
that TB is not the priority of the health care providers indicating that for
early detection there is a need for health care providers to think of the
possibility of TB if they come across symptoms and refer patients for
sputum microscopy examination).
(Source: Table 3.4 End-line survey pp 18)
Most of the health service providers were aware that TB can occur in other
parts of the body as well. There is high awareness that TB can afflict the
lymph, bone, spine and abdomen. This awareness was apparent in both
private as well as public health service providers. Health service providers
are increasingly aware that HIV+ persons are more prone to TB.
Awareness that there is a need to provide information regarding precautions

to patients is also high.
(Source: Table 3.21 End-line survey pp 35).
II- Findings about Causes of TB, TB Prevention and

Diagnosis
Increase in target groups being reached with

information
Among Communities: Repeated communication efforts and reiteration of

focused messages regarding symptoms increased understanding on
symptoms. However, experience has shown that sustained focus in future
communication efforts is required to reinforce and enhance awareness. This
need is reflected in the KAP study findings which documents only a slight
increase in awareness with respect to two of the three most commonly
identified symptoms, i.e. three weeks of cough that persists (73% to 77%),
coughing up of blood (58% to 57%) and fever (44% to 63%);
(Source: Graph 3.3 End-Line Survey pp 17)
Similarly, correct knowledge regarding how TB is spread needs further

reinforcement. Educational campaigns have to address deeply embedded
perceptions and beliefs on a consistent basis. This is again reflected through
the findings of the KAP studies where with respect to mode of spread of TB,
there has been an increase in awareness that it spreads through cough
(62% to 71%), whereas 39 per cent to 69 per cent still believe that TB can
spread through talking, and sharing of bedding, clothing and dishes.
(Source: Graph 3.5 End-Line Survey pp 18)
Studies have shown that a person suspected of having TB immediately

consults a doctor. Even at the time of the Baseline study, the figures were
at a high of 81 per cent for males and 87 per cent for females. This went up
to 93 per cent and 92 per cent respectively at the time of the End line.
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This clearly indicates that people are more aware about seeking health care
services on the onset of symptoms related to TB.
(Source: Table 3.10 End-Line Survey pp 25).
This has implication for case detection rates, indicating that people do seek
treatment, but from the programme perspective it is important that all TB
suspects are referred for sputum microscopy examination and also that the
gap between symptom and diagnosis is reduced.
It has been seen that people do access government facilities and services
for both diagnosis and treatment. The KAP study has documented increase
in preference of government health facilities (from 76% at the baseline to
81%), indicating increase in awareness about good facilities being available
in government hospitals.
In the districts where the KAP was conducted, there has been a slight
decline in the number of people who preferred private centres. The
numbers of people who preferred private health centres went down by 12
per cent points in rural and semi-urban areas (20% down to 8%). One of
the reasons cited for accessing private centres was the distances involved in
accessing government centres.
The programme data shows that large numbers of patients go to private

sector for treatment or private practitioners are the first point of contact for
TB patients. The findings of the KAP studies indicate that more people are
now aware that good treatment facilities are available at government health
centres.
Specific knowledge and awareness of DOTS/TB centres was still low

indicating the need to propagate DOTS and address the issue in advocacy
plans of DOTS especially in far flung areas. This low knowledge is also
documented in the KAP (with only 16% at the End line study as compared
to 10% at the time of the Baseline).
Private practitioners are only preferred for reasons like distances involved in
accessing government/DOTS facilities. Costs and impersonal treatment by
health service providers were other reasons given.
(Source: Table 3.13 End-Line Survey pp 25)
Among Disadvantaged Communities: RNTCP has special provision for

reaching out to disadvantaged and marginalised sections. RNTCP I has
made a special effort to ensure that utilization of RNTCP services by SC/STs
and women is increased. RNTCP II has made special provisions and norms
for providing services in difficult and hard to reach areas. The Social
Assessment and Baseline studies on accessibility and utilisation have
documented the level of awareness about TB; health facilities and treatment
of TB among these communities. These indicate that being a closed and
captive community, the awareness about the location of health facilities in
the vicinity was high. However, distances to facilities which could be
anywhere between 3-15 km from their homes was cited as one of the
reasons for delay in seeking treatment from government health service
providers.
People were more aware about the services for TB being available in
government hospitals than “DOTS”. At some places the patients who were
under treatment were also not familiar with the name “DOTS”.
13
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The Social Assessment study indicated gaps that are prevalent in the
awareness/communication levels with respect to urban slum communities
and tribal populations
Table 1 – Gaps in awareness among Urban slum and tribal

populations
Slum Communities Tribal Populations
Symptoms Unaware of entire Awareness even lower
range
TB patients slightly TB patients were
better aware slightly better
informed
Transmission Awareness high about Contagious nature of
spread of TB disease known
Treatment Patients first visit Tribals are seen to
seeking, chemists/private clinics delay proper TB
duration of and resort to treatment for longer
treatment government hospitals durations of time.
when costs increase Tribals felt over 12
and no cure in sight. months to three years
Generally delay for 1- for the duration of
1.5 months before treatment
seeking proper
treatment.
In urban slums there is
a perception of a delay
of 5-18 months;
migrant workers were
unable to state the
duration of treatment.
There is knowledge
that the disease is
contagious.
Stigma Stigma is still attached

to the disease even
though belief that TB is
curable. More women
than men conceal the
disease than men.
Accessibility Aware of facilities at

government hospitals.
Aware that
government facilities
are available to
access treatment
through AWCs
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Among Opinion Leaders: Opinion leaders have identified that a cough
that persists for three weeks is the main symptom. However, around 80
per cent have also cited coughing up blood as a symptom. This could mean
that they see action to be taken associated only when this symptom occurs.
(Source: Graph 3.1 End-line survey pp15A)
The End line study has shown that opinion leaders were aware that TB
patients should cover their faces while coughing (86%) and use separate
vessels (82%). However, 38 per cent, and 48 per cent had the perception
that TB spreads through talking and sharing bedding and clothing
respectively.
(Source: Graph 3.5 End line-survey pp 18).
III. Findings regarding Method of Diagnosis
Sputum test as most reliable method of diagnosis
Among Communities: Though a large percentage of the general

community has shown a preference to using government health facilities as
indicated in the results from baseline to End line studies, the awareness
about sputum microscopy examinations for TB test is not very high. The
awareness level of that sputum microscopy is a reliable tool for diagnosis of
TB was only 15 per cent at the baseline and 23 per cent at the time of the
End-line.
(Source: Table 3.15 End-Line Survey pp 26).
Among Opinion Leaders: While there has been a steady increase in the
awareness levels that sputum tests are the most reliable form of diagnosis
(88%), 42 per cent who still tend to feel that the X-ray method is reliable
need to be targeted.
(Source: Graph 3.14 & 3.15 End line-survey pp 25, 26).
Among Health Service Providers: Use of sputum test for diagnosis was
found to have increased among Health service providers (both private and
public). 45 per cent of the private practitioners were advising sputum test
(given no other choice) when compared to 55 per cent government doctors.
Availability of services and facilities for sputum test has increased and 97 per
cent of the health service providers reported that they did not face any
problems in regard to this. The percentage of doctors who advise sputum test
every time/most of the time amounts to 81 per cent. Health service providers
have indicated that their diagnosis for cure of TB is ‘positive sputum turning
negative’ as an indicator of cure. However, Health service providers say that
patients do not reassess their status because of fear that relatives/friends
might stigmatise them because of their previous history of TB.
15
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IV. Findings regarding Treatment Seeking Behaviour
Treatment seeking behaviour, accessibility of facilities
General Community: Private practitioners are the first point of contact

even when people are aware of government facilities in the vicinity. Most
people seek medical help from government facilities when symptoms persist
or worsen and when costs incurred mount. There is generally a delay of 1-
1.5 months after TB symptoms are noticed.
Among Disadvantaged Communities: Even though general awareness

among communities is reported to be high in respect of seeking medical
help, and communities are generally aware of TB hospitals within their
vicinity, chemists or private practitioners are first used commonly. Most
people go to the government hospitals only when symptoms persist or
worsen and when costs incurred are high. Generally communities visit
government hospitals only 1-1.5 months after the TB symptoms are
noticed.
Accessibility of Facilities: People are generally aware of TB treatment

facilities in government hospitals (usually 3-15 km in metro cities from slum
areas). Perhaps, urban dwellers preferred private practitioners because of
their proximity to their homes, the personal attention given and their ability
to save on transportation costs to distant government facilities.
Tribal Populations: Most tribals are aware of government health facilities

that are 1-2 kms in the vicinity of the study villages. There was however,
low awareness of the government TB program/DOTS. Information reaches
this community through Anganwadi centres and other auxiliary health
workers.
Health Service Providers: Health service providers have reported that

there was a gradual increase in female patients seeking treatment from 35
per cent in the Baseline to 43.46 per cent in the End line survey.
V. Findings regarding DOTS Campaign
DOTS is the “Sure Way for Complete Cure”
General Communities: The campaign "DOTS - sure cure for TB" launched
in early 2002 has had an impact on the communities targeted. At the time
of the Baseline, 31 per cent were aware that TB is completely curable, by
the End line the level of awareness had increased to almost three times the
numbers at 88 per cent.
The increase in awareness was significant in all the states sampled.

However, these figures need to be treated with caution, as it is not clear
how this question was asked. In the questionnaire, the question is worded
as: Do you agree that DOTS is the sure way for complete cure for TB? The
general tendency on the part of the respondent would be to say that they
agree. There is no further probing as to why they agree or think so.
CTD
The above figures should also be seen in the light of figures shown with
respect to “awareness that TB is completely curable”. 97 per cent among
women were aware of this compared to 90 per cent at Baseline and the
corresponding figure for men was 98 per cent at the time of the End line
when compared to 91 per cent at the time of the Baseline. However, the
general communities were generally unaware that the disease can recur.
(Source: G 3.9, End-line survey pp.21).
It must be stated here that patient interviews carried out as part of internal
evaluations show that a large percentage of patients are aware of the
importance of DOTS - over 70 per cent in most districts; also patients are
more aware of the regimen and importance of regular treatment in almost
all districts
KAP studies have documented a sharp increase in the level of awareness

about the campaign and the slogan “DOTS is the sure way for complete
cure”.
Table 2 - % Households in Agreement that DOTS is the Sure Way for

Complete Cure
States Chattisgarh Himachal Manipur/Megha
Pradesh laya
Baseline 8.5 10.4 0
End-line 95 98 82.4
(Source: Table 3.22 End-line survey pp 39)
The figures showing this sharp increase in awareness however need to be

viewed cautiously as this could mean familiarity with the name “DOTS’ . For
any further studies to be taken up in the future, questions may be properly
worded.
Promising findings in the studies are that:

1) there is an increase in awareness about DOTS being the correct
treatment from the time of the Baseline to the time of the End line (from
18% to 45%) among community members; and
2) that there is an increase in awareness that medicines are available free
in patient-wise boxes.
(Source: Graph 3.12a End line survey pp 38).
Knowledge that "DOTS is available free" in patient-wise boxes has

impacted the general population positively as the figures in the Baseline and
End-line show: from 34 per cent to 94 per cent. Knowledge of DOTS and
that treatment is free was high. However awareness that medicines are
available in patient-wise boxes was low. This component was only included
in the last round of the study and was clubbed with ‘uninterrupted supply of
medication’ due to which awareness was lower on how medicines are
dispensed to patients. (Source: T 3.22 End-line survey pp 39).
The campaign “DOTS is the sure way for complete cure” had also
popularised the availability of free drugs at government health facilities
along with “DOTS sure cure for TB”.
The End line survey has documented the level of knowledge about patient
wise boxes and shows awareness at only 16 per cent.
(Source: Graph 3.29 End-line survey pp 40).
Awareness in the sampled states and districts regarding DOTS, duration of

treatment and importance of completing treatment are given below:
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Table 3 – Awareness regarding DOTS, duration of treatment &

importance of completion
Per cent- DOTS Duration of Importance of
range Treatment Completion of
treatment
81-100 Haryana: Gujarat: Patan; Haryana: WB: Darjeeling;
Kurukshetra; Kurukshetra; Karnataka: Punjab: Gurdaspur,
Punjab: Gurdaspur; Udupi; Kerala: Nawashahr; Assam:
TN: Chennai; WB: Trivandrum; Naibari; Gujarat:
Darjeeling Maharashtra: Nagpur; Patan; Haryana:
Punjab: Nawashahr, Rewari; Karnataka:
Gurdaspur; Tamilnadu: Mysore, Udupi;
Kanchipuram, Chennai; Maharashtra: Nagpur;
West Bengal: Darjeeling Kerala: Trivandrum
61-80 Assam: Naibari; Bihar: Samastipur; UP: Agra; Haryana:
Gujarat: Patan; Jharkhand: E.Singhbhum; Kathial, Kurukshetra;
Haryana: Rewari; Karnataka: Mysore, Karnataka: Belgaum,
Karnataka: Bejapur; Belgaum, Bejapur; MP: Bijapur; MP: Seoni,
Kerala: Trivandrum; Seoni, Ratlam; UP: Agra Ratlam
Maharashtra:
Nagpur; UP: Agra
41-61 Haryana: Kaithal; Assam: Naibari; Bihar: Samastipur;
Karnataka: Haryana: Kaithal Jharkhand: E.
Belgaum; Singhbhum
MP: Ratlam; Punjab:
Nawashahr;
TN: Kanchipuram
21-40 Jharkhand: E Bihar: E. Champaran Bihar: E. Champaran
Singhbhum;
<20 Bihar
Awareness is high that TB is a curable disease and that a completely cured

person can lead a normal life. There was also awareness that TB is curable
if the full course of treatment is taken. However, communities were not
apparently assessed for awareness about the duration of treatment.
(Source: Graph 3.19 End-line survey pp 29)
Disadvantaged Communities: Though disadvantaged communities were

generally aware of symptoms, the need to seek medical help and the
facilities that are available from government hospitals, most were not
specifically aware of DOTS and that tests and medicines are given free.
Opinion Leaders: There is an increase in awareness about DOTS from the

time of the Baseline to the time of the End line (from 44% to 78%) among
opinion leaders. A high percentage of opinion leaders (80%) have said that
they advice potential TB patients to go to a government hospital. And this
percentage has increased from 54 per cent in the Baseline. However, only
31 per cent advice going to a DOTS centre.
(Source: Graph 3.12a End-line survey pp Table 3.30 pp43)
There is need to ensure that large percentage of opinion leaders are able to
motivate patients to seek early treatment; it would also be useful to see
why increase in awareness about DOTS is not communicated to general
community by opinion leaders.
CTD
While there has been an increase in terms of agreement that "DOTS is the
surest way of cure for TB", among opinion leaders since the Baseline
time (from 25% to 58%), 38 per cent still are unsure about this.
"DOTS is available free" has gone up among the opinion leaders since the
time of the Baseline from 17 per cent to 49 per cent (Table 3.22 P 39 EL).
There was also awareness that TB is curable if the full course of treatment
is taken and that it is essential (89%).
(Source: Graph 3.19 End-line survey pp 29).
It is important to ensure that increased awareness among opinion leaders

results in increase in referral and early detection of TB and the message
that it is essential to complete the full course of treatment needs to be
specifically reinforced.
At the time of the End line study, the awareness level regarding "availability
of DOTS in patient wise boxes" was gauged. The awareness regarding this
among opinion leaders was only 23 per cent. However, the component of
patient-wise boxes was only included in the last round of the study and was
clubbed with ‘uninterrupted supply of medication’. This may have led to
responses reflecting that awareness was lower on how medicines are
dispensed to patients.
Availability of good quality anti-TB drugs in patient-wise boxes need to be

addressed in future media campaigns.
Health Service Providers: Ninety four per cent as compared to 67 per

cent are now aware and practice the DOTS regimen. Health service
providers were aware of the facilities of DOTS in their localities. Whereas
among PPs, though 72 per cent were interested in DOTS, only 7 per cent
were DOTS providers. Only 52 per cent were convinced that "DOTS is the
surest way to complete cure" Private practitioners in the DOTS
programme were interested for the following reasons: free tests/diagnosis
of TB (66%) and that DOTS is the surest way to complete cure (52%).
However there is lower conviction that drugs were dispensed in the correct
doses (36% in End line as compared to 61% in Mid term); that there is an
uninterrupted supply of drugs from 55 per cent in Mid term to 43 per cent
at the End line; and that TB patients are welcome for treatment from 43 per
cent at Mid term to 24 per cent in End line assessment. Advocacy
workshops might clarify doubts about DOTS and encourage PP participation
in the programme.
(Source: Table 3.28 p. 42 & Table 3.29 p. 42 – End-line survey).
Public practitioners were not completely aware of private providers who are
involved in DOTS in their areas. The percentage of public providers who
were aware that they could involve PPs as part of the scheme only
increased from 42 per cent to 55 per cent.
Not all DOTS providers were trained in all areas of treatment. There is
general awareness and knowledge about the administration of drugs to
patients on stipulated days, but they lack knowledge of causes, symptoms,
tests and need of regularity of treatment. This is an aspect that can be
included in training modules for health service providers.
19
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VI. Findings regarding Information Source
The source of information about the disease
General Communities: Most of the communities surveyed at the End line,

had heard of the disease through relatives and friends and from doctors.
Awareness has been raised through TV and radio spots, especially in metro
cities.
(Source Graph 4.1, End line pp 43.)
Disadvantaged Communities: At most places, people got their

information about TB and related issues mainly from government
employees, private health service providers, friends and relatives and TB
patients under treatment.
Slum dwellers receive their information from the radio/TV spots mainly in
metro slums. Bus hoardings, street hoardings and wall paintings were
mentioned as main sources of information.
The social assessment in tribal regions too have documented source of

information as friends/relatives and word of mouth by health workers. Mass
media has played a limited role in spreading information in these areas.
Mass Media is reported to be popular in all areas except in tribal and difficult
to reach areas. Hence carefully planned media activities on different popular
channels can reach to larger target audiences. The programme can
consider intensifying media campaign to complement other communication
interventions.
Opinion Leaders: The End line study documents that opinion leaders are
mainly informed about the disease through IEC material and
campaigns/events. Newspapers/magazines are the major source for
opinion leaders in states of AP and Meghalaya.
Health Service Providers: Doctors among the health service providers are
updated and informed mainly through medical journals and
conferences/meetings, information from colleagues, professional bodies and
medical representatives from pharmaceutical companies. Disseminating
information to patient communities is vital as all health service provider felt
and believe that TV should be the main source for dissemination of accurate
information. Awareness campaigns, magazines/newspapers and community
meetings were other modes for generating awareness.
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VII. Findings regarding Treatment Compliance
Duration and importance of completing treatment
Disadvantaged Communities: The social assessment study documents

that all TB patients who were questioned, were aware what they were being
treated for. Slum dwellers felt that the duration of treatment for a complete
cure was 5-18 months, but migrants were unaware of the duration of
treatment. There is high awareness that allopathic medication ensures
complete cure and these populations did not cite home remedies for cure of
symptoms.
Most patients in treatment in the Tribal areas believed TB is curable.

However, those people under treatment were not aware of the duration of
treatment and felt 12 months to 3 years was the duration of time it would
take for a complete cure.
Opinion Leaders: The percentage of Opinion leaders who knew about the
duration of treatment has increased from 31 per cent in baseline study to
60 per cent in the End line study.
VIII. Findings regarding Stigma (prevention & spread)
Is there stigma involved?
General Communities: Stigma is a complex social issue that needs to be

addressed through media campaigns, even though certain practices have
been reinforced within the programme to avoid discrimination. An attempt
was made at the baseline and End line studies to assess attitudes of people
about the disease. These studies have documented “socially accepted”
responses. KAP studies have shown that even though general communities
are aware that TB is curable, there is still stigma attached to the disease.
While 10.34 per cent kept TB patients in the family isolated, the figure went
down marginally to 8.31 per cent.
The Social Assessment study observed that even though communities are
aware that TB is completely curable people tend to hide the fact. Women
more than men tend to conceal their illness mainly from family and friends,
because of the contagious nature of the disease.
Stigma can act as a barrier to starting treatment and/or completing

treatment.
The study on gender conducted by ASCI, indicated that women feel

threatened that they would be discriminated against by and within the
family. There is a difference in the attitudes and practices as regards TB
patients as discrimination towards them continues to prevail. This issue will
have to be dealt with great sensitivity, and may require in-depth interviews
and one to one counselling.
This study has also documented compliance among men and women. It has
found that though women take longer to access services, but once they
21
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start the treatment they are more likely to complete the full course and
completion rates among them are high.
Disadvantaged Communities: The social assessment study which covered

disadvantaged communities in the study indicates that there is stigma in
admitting to having contracted TB especially among migrant workers who
have said that they bury the dead TB patient and not cremate for fear of
spreading the disease. Reasons for concealing the disease were variously
stated as fear of ostracisation from relatives and neighbours,
Opinion Leaders: On the one hand there is a marked difference in the

attitude of opinion leaders pertaining to bias/stigma from the baseline to
the End line studies, in that the opinion leaders do not believe that isolation
of a TB patient is necessary, or that there should be a delay in treatment for
female TB patient etc.
However, there is still evidence that opinion leaders would not share a meal
with a TB patient or marry their wards to a person who has had TB, or
employ a worker who has/had TB, or encourage continuance of studies in a
school if the child comes from a home of a TB afflicted person.
Health Service Providers: Interestingly, while 72 per cent of the health

service providers did not agree that treating a TB patient constituted a risk
for other patients in their care, 62 per cent tended to maintain a distance
from patients, 37 per cent wore masks & gloves.
Prevention of Spread of TB (precautions)
Knowledge regarding prevention
General Community: Prevention and precautions against TB remain

sought after information as shown in the End line. Although not directly
addressed by the campaign the End line study has shown that communities
were aware that TB patients should cover their faces while coughing and
use of separate vessels as important to preventing the spread of TB. To
prevent spread of the disease, communities also said that spitting in public
spaces should be stopped in order to prevent spread of the disease.
(Graph 3.5 End line survey pp 18 and Graph 4.2 pp 44).
However, 38 per cent, and 48 per cent had the perception that TB spread
through talking, and sharing bedding and clothing respectively. There is a
general lack of clarity regarding modes of transmission among general
populations.
Disadvantaged Communities: The social assessment study suggests an

expanded accessibility of services through better infrastructure and
organization for marginalized populations. Suggestions for the
communication plan are outlined in the conclusions and recommendations
chapter at the end of this report.
Opinion Leaders: A high percentage of OL were assessed for their

knowledge of preventive methods during the End line Study. They have
cited covering faces while coughing (86%), use of separate vessels (82%).
(Source Graph 3.5 End line, pp 18)
CTD
IX . Advocacy Efforts with Other Stakeholders
Initiatives to involve Medical colleges, IMA and others
Besides working with the targeted segments talked about earlier, the
Central TB Division has been advocating among other stakeholders such as
medical professionals, their institutions, including medical colleges. Medical
colleges play a critical role in TB control in terms of the sheer number of TB
patients they treat, their standing in the community as opinion
leaders/trendsetters, and their role in imparting knowledge & skills to the
medical students and other practitioners. Thus, it was recognised, that
there was a pressing need for all medical schools to advocate for the
Revised National TB Control Programme (RNTCP) and through this strategy,
provide the best opportunity for cure of patients.
The initiatives taken by the CTD to involve the medical colleges resulted in
consensus among the medical colleges which led to the formation of
national, zonal and state task forces of medical colleges and their meetings
at frequent intervals. The national task force has made 113
recommendations for improving the involvement of the medical colleges in
RNTCP as well as for streamlining their activities. The CTD will in the second
phase continue to support active involvement of the professional
organizations like Indian Medical Association in TB control. Medical colleges
are expected to provide space for the DMC/DOT centre in the hospital,
designate faculty members to oversee the functioning of the centre and
arrange training or sensitisation of their staff through the respective District
Tuberculosis Officer.
An increasing professional consensus regarding the efficacy of the DOTS

strategy has now been reached. A sound strategy for effective involvement
and collaboration between the RNTCP and medical colleges is now in place -
nodal centres have been established, task forces and core committees have
been formed. Regular meetings are held at the national, zonal and state
level to review progress and performances, and to draw up action plans for
the future. By March 2005, 200 medical colleges situated in RNTCP
implementing districts have established a DOTS centre. Thus most colleges
located in RNTCP implementing areas now have first hand experience in
managing TB patients under DOTS and have data on the case diagnosis, as
well as treatment outcomes, of TB patients under their care. Medical
colleges have played an important role, especially in the past two years, in
the national effort to control TB. Data from the 14 “Intensified Public-Private
Mix (PPM) scaling-up” project sites has shown that after the general health
facilities of the public health sector, it is the medical colleges that detect
and treat the second largest number of TB cases.
A notable achievement of the engagement of the RNTCP with the medical

academia of the country, was the publishing in December 2003 of a joint
RNTCP - Indian Academy of Paediatrics, consensus statement on
“Management of Paediatric TB under RNTCP”.
The vision is to make DOTS the standard of care for TB patients in all
medical colleges and their hospitals. It is expected that through their own
practice, medical college professors will influence the practice in the private
sector as well as the future generation of physicians thus making DOTS the
23
CTD
standard of management for TB patients in the country. This will ensure
that all TB patients, irrespective of where they seek care, receive the best
available care, free of cost.
To this end, there is the need to strengthen the efforts made by the
programme to:
( Ensure that all clinical departments of the colleges, in addition to those

departments that run the DOTS centres, are involved and manage their
TB patients as per the RNTCP guidelines.
( Improve on the referral of patients between the various departments of

the college itself, as well as outside the hospital. This assumes
importance as medical colleges often cater to an enormous catchment
area. The Central TB Division is piloting a “Referral for treatment”
mechanism in 12 districts which have a number of medical colleges
situated in the respective districts.
( Establish a reporting system, which will not over-burden the existing

system, but will provide information to the various task forces regarding
the activities undertaken by the medical colleges.
( Develop and work on appropriate operational research in these areas to

guide the development of the programme’s future policies.
Good progress has been made by the programme in this direction and this
component is being reviewed regularly for strengthening these collaborative
activities. Special communication material (material for involvement of
private health care providers-PPM Kit) has also been developed to increase
involvement of private health care providers and health care providers of
other sectors.
A series of sensitisation seminars, training of medical college faculty staff at

Central TB Institutes, national and zonal level workshops were organised to
strengthen this component of the programme.
Advocacy of the RNTCP:

Sensitisation and training through the Indian Medical Association and
other professional bodies;
Workshops and CMEs for medical colleges/and the private sector;
Use of newsletters, the press and other media to spread the RNTCP
message to a wider audience; and
Involvement of the Medical Council of India to enhance the place of TB;
RNTCP in the medical curriculum, and
Conduct Operational Research on relevant topics to RNTCP, such as:
o How to increase case detection of smear positive cases;
o How to improve DOT services;
o Appropriate studies to inform the further development of
consensus guidelines for diagnosis & management of childhood TB
and extra pulmonary forms of TB;
o Management of multi-drug resistant TB;
o Profile and treatment outcomes of hospitalised patients; and
o Diagnosis and management of HIV infected TB patients.
CTD
Chapter 3
State and District - Capacity to Plan and

Implement IEC Activities
During the phase II of the programme, it is envisaged that state and district
level RNTCP staff and partners will have the opportunity to use their
knowledge and experience to come up with effective ways to communicate
with communities they know and work with. While the focus is decentralised
planning and implementation, it was recognised that there was a need to
strengthen the capacities at state and district levels. In order to assess
what was in place in each of the states and their districts, an IEC internal
audit was designed and executed in the form of a questionnaire.
The questionnaire was sent to all states and UTs with clear instructions on
how the questionnaire should be filled using a team effort and participatory
consultation. The idea was that the outcome of the audit would feed into
planning for capacity building in the different states.
The IEC audit covers the following sections:
(Human resources in place and their qualifications and experience

(Institutional capacity and support for IEC at the state level
(Infrastructure/environment
(Financial planning & capacity to implement activities
Audit Outcomes
In all, 32 responses have been received [5 UTs + 27 states]. It may be
noted that: All Information in this chapter and figures relate to the position
as on May 2007.
The compilation of outcomes has been grouped under three categories,
namely:
( Larger states: (10) Tamil Nadu, Karnataka, Andhra Pradesh,

Maharashtra, Madhya Pradesh, Gujarat, Uttar Pradesh, Bihar, Rajasthan
& West Bengal
( Medium sized states: (15) Kerala, Orissa, Assam, Haryana, Mizoram,
Meghalaya, Manipur, Nagaland, Punjab, Uttarakhand, Himachal Pradesh,
Jammu & Kashmir, Chattisgarh, Delhi, Arunachal Pradesh
( Smaller states & UTs: (7): Andaman & Nicobar, Chandigarh, Daman &
Diu, Dadra Nagar Haveli, Goa, Puducherry, Sikkim
25
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I. Human resources in place and their

qualifications and experience
Table 4 below reflects the current position with respect to IEC officers in the
states. As can be seen from the table, in three states and three UTs, the
IEC officer is not in position. In 10 states (large and medium) the IEC
officers are qualified in Mass communications. In 12 states and one UT the
IEC officers have been in service for over three years, while on the other
hand, in seven states they have been in service for just about a year or less
than a year.
Table 4 - Human resources

Larger states Medium sized states Smaller
states & UTs
1. IEC in position Tamil Nadu, Kerala, Orissa, Assam, Andaman &
officer Karnataka, Andhra Haryana, Mizoram, Nicobar, Goa,
Pradesh, Meghalaya, Manipur, Puducherry,
Maharashtra, Nagaland, Punjab, Sikkim
Madhya Pradesh, Uttarakhand, Himachal
Gujarat, Rajasthan & Pradesh, Chattisgarh,
West Bengal Delhi, Arunachal
Pradesh
not in Bihar & Uttar Jammu & Kashmir, Chandigarh,
position Pradesh Dadra Nagar
Haveli and
Daman & Diu
2. Mass Andhra Pradesh, Punjab, Mizoram,
Qualificat Communica Karnataka, Madhya Meghalaya, Himachal
ions tions Pradesh & W.Bengal. Pradesh, Haryana, Delhi
Masters Maharashtra Uttarakhand Goa,
degree/dipl Puducherry
oma (also MBBS),
Anadaman &
Nicobar
Masters in Gujarat, Rajasthan Kerala, Manipur,
Social Work and Tamil Nadu Nagaland & Arunachal
/Sociology Pradesh
Bachelor’s NA Sikkim
degree
3. > 3years Maharashtra, Assam, Haryana, Goa
Duration Karnataka, Andhra Mizoram, Meghalaya,
of service Pradesh Manipur, Nagaland,
Uttarakhand,
Chattisgarh, Delhi
2 years Gujarat & Madhya Punjab Puducherry,
Pradesh Andaman &
Nicobar,
Sikkim
1 year Tamil Nadu & Arunachal Pradesh,
Rajasthan* Himachal Pradesh &
Orissa
< 1 year West Bengal Kerala
* In Tamil Nadu & Rajasthan the earlier IEC Officers have left the job and new
ones have been appointed.
CTD
In terms of communication experience in the field of Public health, table 5

indicates that 14 states and one UT have IEC officers who have had such an
experience. On the other hand, 21 state IEC officers had been exposed to at
least one training under RNTCP. Most of the IEC officers expressed that their
job as IEC officer had been a challenging one in the past one year period. All
STOs (barring W.Bengal & Meghalaya) are involved in developing the IEC action
plans and the STO from Madhya Pradesh has candidly expressed that “there is
still a need for more training and capacity building in IEC”.
Table 5 – Skills & experience of IEC officers & STOs

Larger states Medium sized states Smaller states &
UTs
1. IEC (O) Andhra Pradesh, Kerala, Haryana, None
Have relevant Karnataka and Madhya Mizoram, Manipur,
communication Pradesh Nagaland, Punjab,
experience in Uttarakhand, Himachal
Public health Pradesh, Chattisgarh,
field Delhi, Arunachal Pradesh
2. IEC (O) Tamil Nadu, Karnataka, Kerala, Haryana, Andaman &
Training Andhra Pradesh, Mizoram, Manipur, Nicobar, Goa,
under RNTCP Maharashtra, Madhya Meghalaya, Nagaland, Puducherry,
(at least one) Pradesh, Gujarat, Orissa, Punjab, Sikkim
Rajasthan Uttarakhand, Himachal
Pradesh, Chattisgarh,
Delhi, Arunachal Pradesh
3. Faced Tamil Nadu, Karnataka, Kerala, Orissa, Haryana, Andaman &
challenge as Andhra Pradesh, Mizoram, Meghalaya, Nicobar, Goa,
IEC officer on Madhya Pradesh, Manipur, Nagaland, Puducherry,
the job (last 1 Gujarat, Rajasthan Punjab, Uttarakhand, Sikkim
yr) Himachal Pradesh,
Chattisgarh, Delhi,
Arunachal Pradesh
4. STOs Andhra Pradesh, Kerala, Orissa, Chandigarh
attended IEC Gujarat, Maharashtra, Meghalaya, Delhi,
training (3 yr Rajasthan, W. Bengal Arunachal Pradesh
period)
5. STOs Tamil Nadu, Karnataka, Kerala, Orissa, Haryana, Chandigarh,
responding Andhra Pradesh, Manipur, Nagaland, Dadra Nagar
that they have Maharashtra, Madhya Punjab, Uttarakhand, Haveli, Daman &
the skills to Pradesh, Gujarat, Himachal Pradesh, Delhi, Diu, Sikkim
plan & Rajasthan & West Arunachal Pradesh
implement IEC Bengal
activities
6. Involved in Tamil Nadu, Karnataka, Kerala, Orissa, Haryana, Andaman &
developing Andhra Pradesh, Mizoram, Manipur, Nicobar, Goa,
action plans Maharashtra, Madhya Nagaland, Punjab, Puducherry,
Pradesh, Gujarat, Uttarakhand, Himachal Sikkim,
Rajasthan Pradesh, Chattisgarh, Chandigarh,
Delhi, Arunachal Pradesh Dadra Nagar
Haveli, Daman &
Diu
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Capacity building needs
The state TB cells were asked to respond regarding their confidence levels
in planning and implementing IEC with respect to:
a) Awareness raising to increase understanding about TB amongst: the
public
b) Practitioners across the country so that they know about correct TB
diagnosis and treatment and they refer patients to DOTS services, or
become DOT providers themselves.
c) Advocacy to develop political, administrative and community-level
d) Patient - Provider communication and counselling to help ensure patient
compliance with the treatment regimen, to enhance the reputation of a
patient-friendly service, and to encourage patients and their families to
become advocates for the program.
The tables below (tables 6a, 1b and 1c) provide the capacity building needs
of the State TB cells in the three categories of states, namely, large (10),
medium (15) and small (7) sized states/UTs.
Among the large 10 states, if one were to take the results below, it
reflects that 50 per cent or more of the State TB cells do need capacity
building on planning and implementing for all the four target groups. The
fact that Bihar and Uttar Pradesh do not have an IEC officer in place is
reflected in the low level of confidence as is evident in the table below.
However, it is not clear as to why Andhra Pradesh and West Bengal reflect
an almost similar level of low confidence.
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Table 6 a. Confidence in Planning & Implementing IEC for different
target groups
STATE TB Awareness Practitioners Advocacy to Patient - Provider
CELL raising to across the country develop communication and
increase so that they know political, counselling to help
understanding about correct TB administrative ensure patient
about TB diagnosis and and compliance with the
amongst: the treatment and community- treatment regimen, to
public they refer patients level enhance the
to DOTS services, commitment to reputation of a
or become DOT TB control in patient-friendly
providers India. service, and to
themselves. encourage patients
and their families to
become advocates for
the program.
Andhra Need Fairly Confident Fairly Need Assistance
Pradesh Assistance Confident
Bihar Need Need Assistance Need Fairly Confident
Assistance Assistance
Gujarat Very Confident Fairly Confident Very Very Confident
Confident
Karnataka Need Need Assistance Fairly Fairly Confident
Assistance Confident
Madhya Need NR NR NR
Pradesh Assistance
Maharashtr Very Confident Very Confident Very Very Confident
a Confident
Rajasthan Very Confident Very Confident Very Fairly Confident
Confident
Tamilnadu Very Confident Fairly Confident Need Very Confident
Assistance
Uttar Need Need Assistance Need Fairly Confident
Pradesh Assistance Assistance
W.Bengal Fairly Need Assistance Need Very Confident
Confident Assistance
NR= No response
The table below (table 6 b) provides the capacity building needs of the State
TB cells in the medium sized fifteen states. If one were to take the
results below, it reflects that 50 per cent or more of the State TB cells
among the medium sized states do need capacity building on planning and
implementing for all the four target groups. Of these those needing
immediate attention are the state TB cells of Chattisgarh, J & K, Himachal
Pradesh and Uttarakhand. It may be noted that J & K does not have an
IEC officer in place.
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Table 6.b.Confidence in Planning & Implementing IEC for different
target groups
STATE TB CELL Awareness Practitioners Advocacy to Patient - Provider
raising to across the develop communication
increase country so political, and counselling to
understanding that they administrative help ensure
about TB know about and patient
amongst: the correct TB community- compliance with
public diagnosis level the treatment
and commitment regimen, to
treatment to TB control enhance the
and they in India. reputation of a
refer patient-friendly
patients to service, and to
DOTS encourage
services, or patients and their
become families to
DOT become advocates
providers for the program.
themselves.
Arunachal Pr Very Very Very Very Confident
Confident Confident Confident
Assam Very Fairly Very Fairly Confident
Chattisgarh Need Fairly Fairly Need Assistance
Assistance Confident Confident
Delhi Very Very Very Very Confident
Haryana Very Very Very Very Confident
Himachal Pr Need Need Need Fairly Confident
Assistance Assistance Assistance
J&K Fairly Fairly Fairly Fairly Confident
Kerala Very Fairly Fairly Very Confident
Manipur Very Very Very Very Confident
Meghalaya Fairly Fairly Very Very Confident
Mizoram Fairly Fairly Fairly Fairly Confident
Nagaland Fairly Fairly Fairly Very Confident
Orissa Fairly Fairly Fairly Very Confident
Punjab Fairly Fairly Fairly Very Confident
Uttarakhand Need Fairly Need Fairly Confident
Assistance Confident Assistance
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The table below (table 6 c) provides the capacity building needs of the
small States/UT TB cells in this group. If one were to take the results
below, it reflects that in the overall, there is a high level of confidence in
this group, especially when it came to dealing with general public. Sikkim is
seeking assistance with respect to all 4 target groups.
Table 6.c.Confidence in Planning & Implementing IEC for different

target groups
STATE/UT TB Awareness Practitioners Advocacy to Patient -
CELL raising to across the develop Provider
increase country so political, communication
understanding that they administrative and counselling
about TB know about and to help ensure
amongst: the correct TB community- patient
public diagnosis level compliance with
and commitment the treatment
treatment to TB control regimen, to
and they in India. enhance the
refer reputation of a
patients to patient-friendly
DOTS service, and to
services, or encourage
become DOT patients and
providers their families to
themselves. become
advocates for
the program.
A & N Islands Very Fairly Very Very Confident
Chandigarh Very Fairly Fairly Fairly
Confident Confident Confident Confident
D.N.Haveli Very Very Very Very Confident
Daman & Diu Very Fairly Very Fairly
Goa Very Fairly Fairly Very Confident
Puducherry Very Fairly Very Fairly
Sikkim Fairly Fairly Fairly Fairly
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II. Institutional Capacity and support for IEC

In all the 27 states and five UTs, the TB Cell has a detailed IEC work plan
with budget. The nodal person/s for the IEC action plan is the IEC officer. In
many states, the IEC officer is supported by the STO. The Annual action
plan and the IEC action plan are developed together. As a result of the
above situation, the IEC officer is aware of the budget allocation for both
state and district.
In terms of district plans, the details are as follows. As can be seen from the
table 7 below, 27 districts have not submitted their plans. Among the states
Rajasthan seems to be lagging behind (with 22 districts not having sent
their plan), while Maharashtra, Assam, Gujarat and Karnataka do not have
one or two district plans. Barring Uttarakhand, Rajasthan, and W.Bengal,
the district plans and budgets have been approved by the respective states.
Table 7 Submission of district plans

Total
District plans prepared No of districts districts
by submitted
Annual action
plan-2006-07
Arunachal Pradesh DTO 13 13

Andhra.Pradesh DTO + CFs 25 25
Assam DTO 23 24
Bihar STO 38 38
Chattisgarh DTO 16 16
Delhi DTO/STS/STLS 19 19
Gujarat DTO+ RNTCP staff 27 29
Haryana DTO + CFs 17 17
Himachal Pradesh DTO 10 10
Kerala DTO 14 14
Madhya.Pradesh DTO 45 45
Maharashtra DTO 47 48
Orissa DTO 31 31
Punjab DTO 17 17
Sikkim DTO 4 4
Tamil Nadu DTO 29 29
Karnataka DTO 28 29
Kashmir DTO 6 6
Jammu DTO 6 6
W.Bengal DTO 19 19
Manipur DTO+IEC OFFICER+STS+CFs 9 9
Meghalaya STO+IEC OFFICER 7 7
Mizoram DTO 8 8
Nagaland DTO+IEC OFFICER+STS+CFs 8 8
Uttar Pradesh DTO 70 70

Rajasthan DTO 10 32
Uttarakhand DTO 13 13
Total 559 586
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With respect to utilisation of knowledge of budget allocation in the planning

of IEC activities, very few clear responses have been received. For instance,
in Haryana’s case, the response is as follows:
“Budget allotted as per GOI norms; Budget allotted as per state IEC action
plan/District IEC action plan; after reviewing the SOE of districts”.
With respect to release of budget to districts, among the larger 10 states

four have released less than 25 per cent in the first installment (Bihar, Uttar
Pradesh, Karnataka & Maharashtra). While the others have released 26-50
per cent, only in Andhra Pradesh has it been over 50 per cent.
In four of the 15 medium sized states, the release has been less than 25
per cent (Arunachal Pradesh, Chattisgarh, Haryana & Mizoram). Manipur,
Kerala, Himachal and Delhi have released more than 50 per cent, while the
remaining seven have released between 26-50 per cent.
III. Infrastructure/Environment
Interaction at the state level between programme manager and IEC officer
on IEC issues is important. The IEC audit reflected that in most of the states
both at state and at district level the interaction is very frequent (once a
week, or once a month). However, in the states of Himachal Pradesh,
Mizoram, and Arunachal Pradesh it is only once a quarter or even less
frequent. However, the table on visits to the districts (table 3 below) by the
IEC officer reveals that in many states several districts have not been
visited during the four quarters of 2006.
In most of the states, there is a problem of acquiring a government vehicle

for travel to the districts. Ten states reported that they never get a vehicle,
while eight states said that they do get a vehicle very occasionally. Only two
states Uttarakhand and Nagaland said that they got the vehicle every time.
Thus, the problem of transport is a real problem affecting district level
supervision and support. In Himachal, it was expressed that having to travel
by bus “makes it not only tedious, but one is also bound by bus timings,
thus restricting the time in the field”.
It has generally reported that stock registers, ledgers and records of

patient-provider meetings are checked during the visits. Reports of visits
are submitted by all states barring Rajasthan, Arunachal Pradesh and
Mizoram.
Interestingly, nine states (Arunachal Pradesh, Assam, Meghalaya, Mizoram,

Orissa, Andhra Pradesh, Bihar, Tamil Nadu and Rajasthan have said that
they do not send feedback on their visit outcomes to the districts. Among
the states that do send feedback, it is largely the IEC officer or STO; in one
case the onus was on the officer who visited the district. However, 18 states
have reported that “action points are clearly stated in the letter to the
districts”.
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Table 8 District Visits by IEC Officer/STO
Total districts No of Districts visited
Arunachal
Pradesh 13 0
Andhra.Pradesh 25 9
Assam 24 13
Bihar 38 NR
Chattisgarh 16 8
Delhi 19 18
Gujarat 29 19
Haryana 17 7
Himachal
Pradesh 10 7
Kerala 14 4
Madhya.Pradesh 45 24
Maharashtra 48 3
Orissa 31 18
Punjab 17 14
Sikkim 4 1
Tamil Nadu 29 17
Karnataka 29 24
Kashmir 6 0
Jammu 6 0
W.Bengal 19 4
Manipur 9 9
Meghalaya 7 7
Mizoram 8 5
Nagaland 8 6
Uttar Pradesh 70 NR
Rajasthan 32 9
Uttarakhand 13 8
Total 586 234
Communication Facilitators:
As per the PIP, states have been sanctioned a Communication Facilitator for
facilitation of IEC activities. These facilitators are to support in planning and
organizing social mobilisation activities at district and sub district level. The
communication facilitator could be either an individual, or a group
/institution/ NGO to be determined at state level. The communication
facilitator works with the state TB Cell to facilitate activities across about
five districts.
As per the IEC audit, many states are still to identify the required number of
communication facilitators. Table 9 below provides the details. Out of the 27
eligible states, 15 states have started the process and have appointed
communication facilitators.
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Table 9 – States which have appointed Communication facilitators
(CFs)
No of CFs that No of
Total can be appointed CFs
number of (approximate appoint
districts number) ed
Andhra.Pradesh 25 5 5
Assam 24 5 5
Delhi 19 3 1
Gujarat 29 6 1
Haryana 17 3 3
Kerala 14 3 3
Maharashtra 48 8 3
Under
Orissa 31 5 process
Tamil Nadu 29 6 6
Karnataka 29 5 5
W.Bengal 19 4 4
Manipur 9 2 2
Mizoram 8 2 2
Nagaland 8 2 2
Rajasthan 32 2 2
Total CFs 341 61 44
Note: (these figures are from the questionnaire- as on MAY 2007)
In terms of interaction with the communication facilitators a series of

questions were asked in the audit. The responses are captured below in
table 5. Thirteen of the IEC officers/STOs have responded that they found
having the communication facilitators very useful.
There is still lack of clarity in the states/ districts about the roles and
responsibilities of CF. This area needs a lot of attention from the states and
districts for effective utilisation of additional helping hand provided in the
programme in the districts for IEC component.
Communication Materials
Major activities organised commonly in almost all the states have been
patient-provider meetings, sensitisation for PRIs, AWWs, and CBOs, radio
programmes and TV spots, exhibitions, etc.
In terms of materials, the assessment as to quantities needed is made on

the basis of population, number of health centres, PHCs and as stated in the
request made by the districts. While many of the states have not responded
to this query in the audit, some examples of responses are given below.
Andhra Pradesh: “Material calculated based on the no. of TUs, DMCs,

medical facilities, geographical area and Population”
Gujarat: “1. Calculation of IEC material Distribution is Depend upon the
requirement of the district; 2. Population / Community of the District –
useful of the IEC Material in District. 3. Usefulness of the material is also
seen by the state. 4. No of TU, DMC, DOTS Centre, No of PP, No Of NGOs ,
Medical College, Civil Hospitals , General Hospitals etc.”
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Haryana: “1. According to District IEC Action Plan.; 2.Demands sent by
District; 3. After analysis of the Quarterly Reports 4..No of District TB
Centre / TU/DMC/ PHI”
Table 10– Interactions with Communication Facilitators

Number of Issues discussed
meetings held
Frequency of with CF by
Interaction with CFs IEC officer
Andhra.Pradesh Quarterly 2
Assam No response -
Delhi Monthly 2
1. Advocacy,
Communication and
Social Mobilisation
2. District annual action
plan
3. PP and NGO
Involvement in District
4. DOTS Provider
Involvement
5. New initiative Ideas
and Issues related to IEC
Gujarat Monthly 1 Activity.
Haryana Quarterly 2
Kerala Monthly 1
Meetings to be conducted
Training of CF following the training of
Maharashtra planned - Communication Facilitator
Appointed
Tamil Nadu recently -
Karnataka Quarterly 1
W.Bengal Monthly 3
Manipur Monthly 3
Mizoram Quarterly -
Nagaland Monthly 7
Rajasthan No response -
States have reported sending materials anywhere between the moths of

June to November of 2006.
This is another area which needs attention. As per state annual action
plans, different types of material is proposed to be developed every year,
where as internal evaluations indicate that health facilities do not have
sufficient material for display .Field visits by the central team also made
similar observations. States and districts need to streamline production of
material, its distribution and display and use of this material at the health
facilities and by the programme staff. Maintaining stock register at the state
and districts, physical verification of IEC material during field visits and
reviewing IEC component in the quarterly review meetings will increase
accountability.
In terms of external support from other organisations, many states have

reported that they do enlist support or work in coordination with other
organisations. Illustrative of such coordination are:
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Nagaland: 1. Nagaland State Transport (NST Buses);2.All Nagaland Taxi
Association; 3. All India Radio.
Orissa: State Institute of Health & Family Welfare
Delhi: NGOs in rally in World TB days in various districts
Bihar: Printing Media (ad) Dainik Jagran, All India Radio, NGOs in rally in
World TB days in various districts, ETV Bihar
Madhya Pradesh: IEC Bureau, DHS, DD & Akashwani
Uttar Pradesh: SAHARA INDIA , Uttar Pradesh
While some states have mechanisms to record such contributions, others do

not. The states which did have such a mechanism were: Nagaland, Orissa,
Delhi, J &K, Karnataka, and Bihar.
The advantages seen by these states from such collaboration were:

“Development of partnership for activities leading to networking and free TB
Control activities”
“Better penetration, acceptability and mobilisation; and potential for
innovative ideas etc”
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IV. Financial Planning & Capacity to Implement

Activities
As mentioned earlier, all the states have their annual action plans as well as
district level plans. The state TB cell is also provided with a budget based on
population. State TB Societies are provided 10 lakhs, 7 lakhs and 5 lakhs
(depending on the size of the state) and each district within a state has
budgetary norm of Rs. 75,000 per million population. The budget provision
for urban population is Rs.1.5 lakh/million population. These budgetary
norms are indicative and there is lot of flexibility provided activities are
reflected in annual action plans and justified.
The expenditure against allocated sums indicates the capacity to implement

activities as well as the level of financial planning at state level as also the
nature and extent of support provided to specific districts. It may be noted
here that the states of Madhya Pradesh, Mizoram, Punjab, Tamil Nadu
Haryana, Chattisgarh, and Assam reported that activities were partially
carried out in 2006 (as per action plan).
The State level expenditures (table 11 & map) show that 16 of the states
have been able to spend below or just around 50 per cent of the allocated
sum. The states which need to improve are: Uttar Pradesh, Bihar, Andhra
Pradesh, Gujarat, Karnataka, Maharashtra, and Tamil Nadu. On the other
hand, several states reflect extremely high percentage of expenditures.
Table 11 Percentage Expended by State TB cells (against budget

allocation)
States Per cent States Per cent
expended expended
49 Arunachal. 99
Bihar Pradesh
Chattisgarh 51 Andhra.Pradesh 317*
Himachal Pradesh 57 Delhi 378*
Kerala 31 Gujarat 265
Orissa 40 Haryana 263
Punjab 34 Maharashtra 156
Sikkim 82 Tamilnadu 101
Tripura 26 Manipur 213
Karnataka 34 Mizoram 118
Kashmir 39 Nagaland 144
Jammu 4 Assam 72
W.Bengal 52 Madhya.Pradesh 77
Meghalaya 45
Uttar Pradesh 1
Rajasthan 17
Uttarakhand 2
Jharkhand 30
* These states have spent more than allocated budget at the state level,
indicating that many of the activities have been organised by the state on
behalf of districts. Printing of material is one of the main activities which
states have been undertaking on behalf of districts.
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39
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All state level expenditures that are more than 100 per cent indicate that these
states are spending more than the budget allocation as per norms at the state TB
cell. This also indicates that many states are spending on behalf of districts
especially for development of material. Apart from development of material,
district level activities show poor utilization of funds. It is relevant to note here
that data from the internal evaluations indicated that not enough material is
displayed at health facilities indicating dichotomy between the spending at the
state level for development of communication material and its distributions and
utilisation in the districts.
An analysis of percentage expended based on allocation showed that of the

619 districts from 29 states, 22 per cent of the districts had expended
between 75-100 per cent of the allocated budget. On the other hand, 34 per
cent of districts had expended less than 25 per cent of the allocated budget
and an overall 64 per cent had expended less than 50 per cent of the
allocation.
Interestingly, as table 12 below indicates that even though some state TB

cells have released higher amounts to the districts, in these states a larger
number of districts have expended their budget amount.
The details for some of the states where districts spent less than 50 per
cent are as follows:
In Andhra Pradesh 23 out of 25 districts spent less than 50 per cent of

allocated amount;
in Kerala 8 districts out of 14 spent less than 50 per cent of allocated
amount;
in Himachal Pradesh six districts out of 10 spent less than 50 per cent of
allocated amount;
In Delhi 13 districts out of 19 spent less than 50 per cent of allocated
amount.
Only in Manipur all nine districts reflect over 100 per cent expenditure of
allocated amount.
In the case of Gujarat and Maharashtra, per cent expenditure at the state
TB cell was 265 per cent and 156 per cent respectively. However, the
district picture (see maps) shows that only two districts in Gujarat had
expended more than 100 per cent of permissible amount, while 19 districts
had expended less than 50 per cent of permissible amount. (It may be
noted that maps do not show all districts). Similarly, in Maharashtra, while
only three districts had expended over 100 per cent, 31 districts had
expended less than 50 per cent.
One of the reasons is that districts get less than the eligible budget under
IEC head. The maps below show spending against the eligible budget, not
as against the actual releases.
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Table 12 Percentage expenditure by budget allocation by number of
districts
26- 51- 76- Total
50 75 100 distri
<=25% % % % cts
Arunachal.
Pradesh 1 0 0 12 13
Andhra.Pradesh 15 8 0 2 25
Assam 1 4 4 15 24
Bihar 37 1 0 0 38
Chattisgarh 8 6 1 1 16
Delhi 7 6 4 2 19
Gujarat 13 6 6 4 29
Haryana 7 7 3 0 17
Himachal
Pradesh 2 4 1 3 10
Kerala 1 7 3 3 14
Madhya.Pradesh 6 19 15 5 45
Maharashtra 11 20 6 11 48
Orissa 3 11 6 11 31
Punjab 11 3 3 0 17
Sikkim 1 2 1 0 4
Tamil Nadu 12 4 7 6 29
Tripura 1 2 1 0 4
Karnataka 17 7 2 3 29
Kashmir 2 2 1 1 6
Jammu 1 1 2 2 6
W.Bengal 8 3 4 4 19
Manipur 0 0 0 9 9
Meghalaya 2 0 0 5 7
Mizoram 0 0 0 8 8
Nagaland 0 2 1 5 8
Uttar Pradesh 20 31 14 5 70
Rajasthan 9 7 6 10 32
Uttarakhand 6 4 3 0 13
Jharkhand 9 6 4 3 22
Total 211 173 98 130 612
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Chapter 4
Conclusions and Recommendations

Following the research process at three levels, i.e., the baseline, Mid term
and End line, and the social and gender assessments studies, the internal
evaluation and the IEC capacity audit, a thorough assessment has been
conducted and findings of the communication needs and the changes in
knowledge, attitudes and practices of the target groups now provides
sufficient data to gauge the overall impact of communication on the target
groups. These findings can accurately further inform the implementation
plans for the Phase II of RNTCP across the country.
There are several issues that have surfaced that need to be addressed if not
already done in the next phase and they are listed below:
Advocacy, Communication & Social Mobilization for

Increasing and Strengthening Awareness (general about
TB and with relation to results framework indicators)
1. General awareness about TB among rural communities, opinion leaders,

and slum and urban communities as well as among health service
providers is high.
This level of awareness can be further increased and sustained. Specific

attention would be needed to address the migrant population which is ever
increasing, especially the younger work force in urban slum communities.
Consistent technical information would need to be provided to health service

providers in the private sector.
2. The awareness among marginalised tribal communities is still low.
There is a need to improve and sustain communication networks and to

widen the reach of information to raise public awareness among
marginalised and difficult to reach tribal communities.
3. Awareness that sputum test is the most reliable method for diagnosis
has increased to about 23 per cent among communities. Among opinion
leaders, 42 per cent still have faith in X-ray as a tool for diagnosis. There
is also the problem of patients not returning for sputum examination for
reassessment of status.
Since more and more health service providers (public & private) are
recognizing the importance of the sputum method they can be further
equipped to become convincing and powerful communicators on this count.
4. Health service providers say that patients do not reassess their status
because of fear that relatives/friends might stigmatise them because of
their previous history of TB.
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Specific communication messages need to be designed so that patients

realise the importance of the need to reassess their status and the need to
have sputum tests done as advised by doctor /DOTS provider. Patient
counselling during the course of treatment will also enhance compliance for
end of treatment sputum test.
5. While there is high awareness regarding “DOTS being the surest way to
cure”, there is lower awareness regarding DOTS being available free and
in patient-wise boxes.
Message regarding availability of DOTS free and in patient-wise boxes needs

to be reinforced at all service points both at private and public service
points. Special meetings with patients and camps need to popularise this.
More attention needs to be paid to disadvantaged and tribal communities.
Media campaigns planned in the future need to take up this issue on a
priority basis.
6. In the case of disadvantaged and tribal communities and even in the

case of opinion leaders there is incomplete understanding regarding
duration of treatment. Mass media has played an important role in urban
areas.
Advocacy through methods other than mass media needs to be planned

specifically on this count for rural and tribal regions.
7. Stigma based on deep rooted perceptions and gender issues pertaining

to the disease remain a complex issue.
Inter-personal communication and counselling and having patient friendly

environment at the health facilities can have a significant impact.
Other forms of advocacy methods that are effective and convincing as well
as social mobilisation can have a significant impact.
8. It has been seen that people do access government facilities and services
for both diagnosis and treatment. However, one of the reasons cited for
accessing private centres was the long distances to government centres.
Distances involved and time spent in accessing services is a barrier to
utilisation of services for potential patients. This is an issue in urban
slums and tribal regions. Also only a little over half of the public
providers were aware that they could involve PPs as part of the scheme.
Alongside, popularsing the location of health centres, good interpersonal

communication and provision of sputum collection centres as per RNTCP II
where distance from the health facility is an issue, would go a long way in
addressing this issue. Identifying increasing number of local DOTS providers
and training them (private providers, cured patients, and others) needs to
be given consideration.
Advocacy with private practitioners needs to be strengthened so that correct

and precise messages are transmitted to the patients who use them as first
point of service; advocacy with public providers is needed in order to
encourage them to enlist the support of PPs for the scheme.
CTD
Institutional Strengthening & Capacity Building
1. It is a very positive step that almost all large and medium states have
IEC officers. However, the fact that two critical states (both from a
population size point of view as overall low development indicators
perspective) such as Bihar and Uttar Pradesh do not have IEC officers
needs immediate attention.
The two states must place this as top priority action; in the case of Uttar
Pradesh considering the sheer size of the state, the IEC officer and
communication facilitators need to be in place at the earliest. The state may
consider having more than on IEC officer for the state.
2. While almost all IEC officers have been exposed to at least one IEC
training organised by Central TB Division, many of the state TB cells
have expressed a lack of or a low level of confidence in planning and
implementing IEC programmes whether it is for general public or political
and administrative officials or private practitioners or patient level
counselling.
Capacity building in ACSM needs to be planned and implemented on a

regular and ongoing basis. The Centre may consider having joint
training/workshop of state TB officers and IEC officers. District programme
staff also need to be formally trained for planning and executing ACSM
component of the programme.
3. The IEC capacity audit has been a very positive step, in terms of
responses as also the feedback from the regular monitoring visits and
internal evaluation. This has highlighted that a beginning has also been
made with respect to the appointment of communication facilitators.
The identification of the required number of CFs, their training and

positioning needs to be taken on an urgent footing.
In each region, workshops would then need to be organised with focus on:
( IEC planning and budgeting skills
( ACSM concept and techniques
( Monitoring on the basis of result framework.

CTD
Annexure 1
IEC Capacity Audit at the State Level

Background
IEC is an important component of RNTCP. The focus of IEC in Revised

National TB Control Programme is on three main areas, i.e. Awareness
generation, Advocacy, and Patient-Provider communication and counselling.
Awareness raising to increase understanding about TB amongst:

the public so that they make use of RNTCP services
practitioners across the country so that they know about correct TB
diagnosis and treatment and they refer patients to DOTS services, or
become DOT providers themselves.
Advocacy to develop political, administrative and community-level
Patient-Provider communication and counselling to help ensure patient
compliance with the treatment regimen, to enhance the reputation of a
patient-friendly service, and to encourage patients and their families to
become advocates for the programme.
The IEC strategy in RNTCP envisages that:
IEC is a long term commitment wherein IEC is process and not product
oriented, and implementing IEC activities is based on analysis of the
needs. We aim to develop a strategy to plan need-based, locally
appropriate activities. Communication strategies for TB control takes
care of opportunities for interactive communication, such as engaging
cured patients to convince and support others, group meetings to
discuss all aspects of TB control, including the social aspects.
It focuses on decentralised planning, choice of communication channels
and monitoring to ensure contextual relevance and wide reach of
information. The states and districts have to take active part in this
process while the Centre continues to provide leadership, develop core
messages, mass media and advocacy events.
IEC takes care to address social issues related to TB such as stigma and
gender, and special communication initiatives to address the needs of
the special groups and ‘hard to reach populations’.
Capacity of State for planning and implementing IEC activities
Objective of this exercise- IEC Capacity Audit
During this phase of the TB Control Programme, it is envisaged that state

and district level RNTCP staff and partners will have the opportunity to use
their knowledge and experience to come up with effective ways to
communicate with the communities that they work with and know. The
centrally engaged media agency will provide leadership of the mass media
component. The states and districts will lead the more interactive locally-
based communication, while at the same time dovetailing with the mass
media campaigns.
Each state will undertake an IEC audit to take stock of its current capacity
to fulfil the objective: Increase in state and district level capacity to
plan and execute IEC activities. The purpose is to assess capacity to
CTD
improve the reach of information and communication about TB and DOTS.
An audit is a way of taking stock of where we are right now. It is not a
judgment of our efforts. Therefore, this is an opportunity to think about how
ready the state level TB cells are to take more responsibility for planning
IEC activities. So the audit should be a participatory process in each state
facilitated by an external facilitator. This IEC capacity audit is a step to
document what exists at this point of time.
Who should participate in completing the audit?
The questionnaire needs to be filled by the state under the

supervision/oversight of an external member. The team should include:
State RNTCP staff:
STO
IEC officer
External facilitator to be identified by the state TB cell. Consider one of
the following:
x Representative of research organisation;
x Academic from a department of community health or medical college
x WHO consultant.
How to conduct the audit
1. Circulate this questionnaire to the above.

2. Gather relevant information.
3. Plan a meeting of at least half a day for discussions and to complete the
questionnaire.
4. During the meeting, discuss and reply to each question as fully and
honestly as you can. Remember, we are wanting this information to
document the situation now so that we can know what is needed to
support state and district level IEC, and also so that we can compare it
later to assess if these aspects improve over time.
5. Once completed, date the questionnaire, and each participant should sign.
CTD
Questionnaire for IEC Capacity Audit
A. Human resources / Background and technical expertise of staff
A1. Is there an IEC officer in place? A2. Date of appointment

Y N
A3. Qualifications of the IEC Officer
A4. Has the IEC officer attended the RNTCP training in IEC?
Y N
If yes, when?
A5. Relevant experience of the IEC officer during the past 3 years
(This could be in any communication field, not only TB)
A6. Has the IEC officer experienced any notable challenge in doing the job over the
past one year?
Y¥ N
Describe the challenges experienced by the IEC Officer in doing the job over the
past one year
A7. Does STO consider himself /herself having the skills for planning and
implementing IEC activities in the state?
Y N
If yes, specify these skills.
A8. Has STO attended any training relevant to IEC in the past 3 years?
Y N
If Yes, please describe
A9. Has STO had any prior experience of involvement in IEC in any other public
health programme?
Y N
If yes, describe.
CTD
A10. Has STO been involved in preparing IEC annual action plans?
Y N
A11. Has STO experienced any challenges in doing IEC activities in past one year?
Y N
List the main challenges faced by the STO for planning and implementing IEC in
his/her state?
1.
2.
3.
A12. How confident is the State TB Cell as a whole to plan and implement IEC for
the following:
i) Awareness raising to increase understanding about TB amongst:

the public so that they make use of RNTCP services
Very confident fairly confident need outside assistance
Practitioners across the country so that they know about correct TB diagnosis and
treatment and they refer patients to DOTS services, or become DOT providers
themselves.
ii) Advocacy to develop political, administrative and community-level commitment

to TB control in India.
iii) Patient - Provider communication and counselling to help ensure patient

compliance with the treatment regimen, to enhance the reputation of a patient-
friendly service, and to encourage patients and their families to become advocates
for the program.
Very confident fairly confident need

outside assistance
B. Institutional Capacity and Support for IEC at the State
B1. Does the State TB Cell have a detailed IEC work plan and budget allocated for
IEC?
Y N
B2 a. Who is the nodal person for developing the IEC Annual Action Plan in the
state? IEC Officer
B2 b. Is IEC Annual Action Plan prepared along with the annual action plan?
Y N
CTD
B3. Is the IEC Officer aware of the budgetary allocation at the state and district
level?
Y N
B4. How IEC Officer utilizes this knowledge about the budget allocation in planning
IEC activities in the state and districts?
B5. What percentage of required budget for IEC (as per the proposed annual action
plan) was released as first installment by the states to the districts, and when (how
many months after receiving the money from CTD) in the year 2006-07?
< 25% 26-50% > 50% Not released at all

within 1 month it was released to all the Districts
B6. What is the total budget allocation for IEC at the state level :
B6 b What percentage of this budget has been spent till December 2006 (March
2007) :
B6 c. If less than 50%, indicate the reasons for low expenditure
B7. How frequently IEC officer interact with the program manager at the State and
District about IEC issues/programs/plans?
More than once a week Once a week Once a month Once every quarter
Less than once every quarter
B8. How many districts have been visited by the IEC Officer in four quarters (April
2006- March 2007)?
B 8 a. How many districts have not visited at all during this period?
B9. What specific activities and records does the IEC officer see during the field visit
to the districts? Indicate the records
B10 a. Does IEC Officer submit report to STO after each visit?
Y N
B10 b. Is the feedback sent to the districts?

CTD
Y N
B10 c. Who is responsible for communicating the observations of the field visit to
the concerned districts?
B10 d. Are the action points clearly stated in the letter?

Y N
B11. How many communication Facilitators have been appointed so far by the State
2 (two)
Details of Communication facilitators appointed (use extra sheet, if list is long)
Name of NGO/ Date of Number/names of districts

Communication appointment assigned
Facilitators
1.
3.
4.
5.
6.
B12 a. How frequently interaction meetings between IEC Officer and

Communication Facilitators undertaken?
Monthly Quarterly
B12 b. Number of meetings held with the communication facilitators and IEC Officer
at the State TB Cell in the past quarter (Jan 2007- March 2007)
B12 c. What are the main issues that have been discussed in the meetings
B13. What system is followed for providing payments / honorarium to the

Communication Facilitators- (monthly/ quarterly), State the problems, if any
B14. What system is followed for travel reimbursement to the communication

facilitators (Monthly/ Quarterly). State the problems, if any
B15. Does STO/IEC Officer find the role of communication facilitators useful?
CTD
Y N
State the reasons for Yes or No
C. Infrastructure/Environment
C1. How frequently IEC More than

Officer gets opportunity to once a week
access electronic materials Once a week
and websites on the Once a

computer in the state TB month
cell Once every
quarter
Less than
once a
quarter
C2. List the materials which the State TB cell has adapted/reproduced and/or
produced during the last one year (April 2006- March 2007)? Specify months
Name of materials Date/ Quantities reproduced

adapted/reproduced from the month
RNTCP Web based resource reprod
Centre uced
C3. Other materials produced Date Quantities produced

produc
ed
C4. On what basis the requirement of quantities of material to be produced and

reproduced was calculated?
C5. When was IEC material sent to districts by the state in last one year (April
2006- March 2007? (Specify month/s)
C.5 a. What was the basis of calculation of requirement of IEC material for each
district?
C6. Is there a stock register for IEC material at the STCS?

Y N
CTD
C7. How many times has it been possible for IEC Officer to get an official vehicle
from the State TB Cell to visit districts in the past 6 months (October 2006- March
2007)?
Never Every time¥ occasionally, Specify the number in

last six moths ………..
What is the alternative transport arrangement for IEC Officer to visit districts
C8. Does IEC Officer/ Communication Facilitators get official vehicle at the District
level to make visits within the districts?
Never Every time occasionally¥, Specify the number in

last six moths :
What is the alternative arrangement for IEC Officer/ communication Facilitators to

make visits within districts in the absence of official vehicle
State any difficulties faced in this regard
D. Other resources to draw on for IEC activities
D1.a. Are there any external organizations/ individuals contributing to the IEC
activities of the state?
Y N
D1.b. List the organizations (government, NGO and commercial) who contributed to
state level IEC during the past one year
D2. Does the state have any mechanism to record their contribution?
Y N
If Yes enclose the copy of the relevant record
D3. List two main advantages of collaborating with these agencies
E Capacity of the districts for planning and implementation IEC activities
E1. Have all districts submitted IEC annual action plans to the State in last year
2006-07
CTD
Y N
How many districts have submitted district annual IEC action plan to the state for
the year 2007-08
E2. Who is responsible for developing IEC annual action plan in the districts?
E3. Has the action plan been reviewed by the state and budget approved?
Y N
E4. Have all districts been released IEC budget in 2006-07?

Y N
E 4. a. What percentage of total IEC budget allocation has been released to the
districts by the state in the year 2006-07?
100% 60-99% Less than 25-59 % Not released at

all
E 5. How many districts have had the second installment released under IEC head in
2006-07?
E 6. How many districts have spent less than 25% of the allocated budget in 2006?
E 7. Do all districts have communication facilitator?

Y N
E 8. Major IEC activities organized in the districts in last six months
E 9. How many districts have submitted quarterly report on IEC activities to the
state in last four quarters (April 06- March 07)
E10. How many districts in the state have conducted IEC activities in each quarter
as per the IEC annual action plan
E11. How many districts have been sent feedback on quarterly IEC reports -
E.11 a Were quarterly reports / report of the IEC Officer discussed in the last two
DTOs review meeting?
CTD
Y N
Please complete the following sentence:
We think that this State would be able to do IEC for TB control better if……
………………………………………………………
STATE Date
………………………………………………………………………………………….
(Name and signature of STO)
AO……………………………………………………………………………………………….
(Name and signature of IEC officer)
……………………………………………………………………………………………….
(Name and signature of outside facilitator)
&Thank you for completing the IEC State capacity audit!

IEC Baseline Document For RNTCP

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Report compilation: New Concept Information

The RNTCP is an application in India of the WHO-recommended Directly

The RNTCP strategy aims to ensure political and administrative commitment

The IEC strategy mainly focuses on awareness generation, advocacy and

The target groups are three clear segments:

This Baseline IEC document summarises information about the health

This report is a compilation of results gleaned from the above reports, as

 Increase in the level of awareness about TB diagnosis and DOTS

1. While general awareness about TB among rural communities, opinion

4. Regarding duration of treatment, there is incomplete understanding among

6. Stigma based on deep rooted perceptions and gender issues pertaining to

9. In terms of institutional capacities, it is a very positive step that almost all

Several recommendations emerge from the studies conducted. These may

State/districts need to pay further attention to increasing level of awareness

 Treatment and its duration

 Consistent technical information would need to be provided to health

Similarly with respect to the appointment of Communication Facilitators

Over all there is need for intensive media campaigns in order to

 Messages regarding provision of drugs in patient-wise boxes also need to

( IEC planning and budgeting skills;

State TB Officers feel confident to conduct and undertake IEC activities in

This continued burden of disease is particularly tragic because TB is nearly

Revised National Tuberculosis Control Programme (RNTCP)

The RNTCP in India is an application of the WHO-recommended-Directly

The components of the strategy to control the spread of TB are:

1. Political and administrative commitment at all levels

Since March 2006, The Revised National TB Control Programme is being

The TB Control Programme aims to further increase access to services for

RNTCP gives special attention to the following activities to ensure equitable

IEC (Information, Education and Communication) Strategy for

Advocacy and communication is a central and integral part of the Phase II

With the Tuberculosis Control Programme now operational across India,

1. To raise awareness of:

2. Advocacy to develop political, administrative and community-level

3. Improved patient-provider communication and counselling

 to ensure patient compliance with treatment regimen;

The target groups are three clear segments. These are:

 Patients, & their families

 Health Providers (Public & Private)

A number of initiatives have been taken in RNTCP to address health

Information about the health communication initiatives and its impact/

This Baseline IEC document is designed to give comprehensive information

( A Mid term study was conducted in November 2004 to gauge the

( The End line assessment followed in May 2005 to review the

Four specific respondent categories were covered in this IEC impact

The IEC audit covered the following:

( IEC staffing and positioning, their academic background and skills

Every quarter, each state conducted internal evaluations of two of their

 Increase in the level of awareness about TB diagnosis and DOTS

The three KAP studies, conducted by Centre for Media Studies in

Studies of accessibility and utilisation of RNTCP services by the marginalised

 General awareness about TB being a common disease

Among Urban Slum Dwellers/Migrant Workers/Industrial Workers:

Among Tribal Populations: In the Social Assessment studies conducted,

Tribal women believed that TB was prevalent among their communities

Among Opinion Leaders: Overall, the spontaneous recall (without

In the Baseline study in 2002 a question was asked as to whether health

Awareness that there is a need to provide information regarding precautions

II- Findings about Causes of TB, TB Prevention and

 Increase in target groups being reached with

Among Communities: Repeated communication efforts and reiteration of

Similarly, correct knowledge regarding how TB is spread needs further

Increase in the level of awareness about TB diagnosis and DOTS

Treatment and its duration

Consistent technical information would need to be provided to health

Messages regarding provision of drugs in patient-wise boxes also need to

to ensure patient compliance with treatment regimen;

Patients, & their families

Health Providers (Public & Private)

Increase in the level of awareness about TB diagnosis and DOTS

General awareness about TB being a common disease

Increase in target groups being reached with

Sputum test as most reliable method of diagnosis

Treatment seeking behaviour, accessibility of facilities

DOTS is the “Sure Way for Complete Cure”

The source of information about the disease

Duration and importance of completing treatment

Is there stigma involved?

Prevention of Spread of TB (precautions)