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Quality of RTI/STI Case Management Services in India: Perspectives and ChallengesTable 1. Management of RTIs at Different Levels of the Health Care Delivery System: Some OptionsCommon RTIs Sub-centre health workers-F/M PHC CHCs /hospital out-patientdepartment)Candidiasis + a + +Bacterial Vaginosis (BV) Presumptive diagnosis + +Trichomoniasis - + +Syphilis b - + +GonorrhoeaNot for women; Syndromicalgorithm for men + +Chlamydia c - + +Pelvic InflammatoryDisease (PID) - - +Facilities Standard check list, speculum, Standard diagnostic criteria, Standard diagnostic criteria,litmus paper, potassium microscope, technician microscope, technician trainedhydroxide trained in wet mount & Gram in wet mount, Gram stainstain VDRL/RPRre-techniques VDRL/RPR &TPHA tests & maybelaparoscopy for identifyingPID diagnosisa+ denotes what can be done at the stated level of health care; - means it is not possible.bWhere syphilis is known to be prevalent, every attempt should be made to equip PHC with the VDRL test.cMore than 10 Pus cell/HPF on microscopic examination (should be treated for gonorrhoea and chlamydia).Currently, laboratory techniques for detection of gonorrhoea and chlamydia are complex andexpensive and not cost effective, especially for chlamydia. The need for simple, reliable, lowcosttests to diagnose gonococcal and chlamydial infections among women, particularly amongasymptomatic women, remains a priority.Routine screening of pregnant women should also incorporate examination for candidiasis, BV,and trichomoniasis in symptomatic women. Screening for syphilis should be initiated in aphased manner beginning in areas where prevalence is known to be high. Similarly, specificinterventions need to be designed to reach out to female sex workers and bridge populations.Utilization of health services will also depend on the perceived quality of the services by theclients. Service providers need to be sensitive to the needs of clients and to be nonjudgemental.Decentralized IEC interventions in district settings specifically integrate communicationobjectives related to improved treatment-seeking behaviour and also target differentproviders in the district to emphasize the importance of quality management of STI patientsseeking treatment with them. One generic dimension of quality that is likely to improve isthe nature of provider-client counselling. Promotion of safer sex behaviour, andencouraging the utilization of clean, safe delivery and abortion services should be theobjectives of communication interventions. This calls for addressing all personnelincluding traditional birth attendants (TBAs) involved in obstetric care. Communicationefforts should also be directed to build partnerships with men for responsible sexual164
Quality of RTI/STI Case Management Services in India: Perspectives and Challengesbehaviour and to stress the importance of early treatment from qualified/trained serviceproviders. At the community level, the syndromic approach in men with urethral dischargeand genital ulcers seems to work well in detecting STIs, although its use needs to bevalidated in India. It is also quite possible that men will be more likely to bring in theirpartners for treatment and vice versa, and this may lead to identification of asymptomaticwomen. Public sector facilities providing STI services are predominantly MCH/FP basedand are targeted mainly at women and thus may be unavailable to men. A study inBangladesh (Hawks et al., 1999) has demonstrated the feasibility of establishing STI clinicsfor men, within the existing STI/MCH and family planning system. The activity wouldincorporate not only STIs but provide comprehensive sexual health services for men.Addressing STIs in men will have financial implications in the form of training the existingcadre of male health workers, establishing links with pharmacists and the private sector,and referring patients for medical evaluation and counselling.CostsWorldwide, the cost of adding STI services to the existing list of services offered is a concern tofamily planning programmes. Establishment of any new service involves additional costs,whether provided in combination with other services or not. Costs will vary according to thetreatment regimen offered, services delivered by health workers or physicians, possible casedetection opportunities, diagnostic options, screening services, partner management strategies,IEC, and types of targeted interventions. Additional costs are to be considered in cases wherepregnant women need to be screened for syphilis.PartnershipsIn India, the private sector provides 82 percent of out-patient days of care (National Council ofApplied Economic Research, 2000). Programmes should strive to establish linkages withnetworks of private practitioners for improving the quality of services offered through conductof orientation/training programmes. Focus should be on the use of protocols, counselling, andco-treatment. Similarly, social franchising, which will entail running clinics to achieveobjectives of providing quality care and enhance equity in access, needs to be give a fair trialunder the social marketing programme.Epidemiological ChallengesEvidence from the studies conducted across the country during the last decade deserves seriousattention. There is a continued preponderance of genital ulcer disease (syphilis, chancroid,herpes, and granuloma inguinale) in the country’s STI profile, accounting for close to 75 percentof all STIs. Also, bacterial and treponemal STIs continue to dominate the reported STI profileacross the country as they did during the 1980s. The rise in the incidence of viral STIs, again awidespread phenomenon, is also a matter of concern. Emergence of viral STIs (e.g., HSV1 and 2,HBV, and HPV) are posing new challenges for adopting appropriate screening techniques andtreatment options in low-resource settings. There are reports indicating a high degree ofassociation between HSV-2 and HIV infection with respect to prevalence, stage of HIV infectionand viral shedding of HIV, and HSV-2 among high-risk behaviour groups. The increasing trendin the number of young people reporting to different clinics with STIs is another matter of165
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Health Policy IssuesandHealth Progr
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ContentsContentsPrefaceList of Part
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I would also like to thank our tech
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List of ParticipantsIndu Kumar Pand
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List of ParticipantsMohmed ShaukatD
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List of ParticipantsR K PurohitAddi
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GlossaryGlossaryAbbreviationsAIIMSA
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GlossaryLHVLILMISMAPMCMCHMDRTBMDTM&
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GlossaryTHRTRCTRIPsTTTUUDCUIPUPUTVC
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Inaugural Sessionwould be the first
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Inaugural SessionOnly 18% of the pr
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Inaugural SessionMadhukar Gupta, Ch
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Inaugural Sessionrotational basis f
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Inaugural Sessiontell you more abou
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Public Health Issues, Priorities, a
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National Health Programmes: An Over
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Implementation of National Health P
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Use of Epidemiological Surveillance
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Designing a Surveillance SystemFurt
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Designing a Surveillance Systemsurv
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National Health Programme in Uttara
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IEC Strategies for Health in IndiaS
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IEC Strategies for Health in Indial
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IEC Strategies for Health in IndiaS
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IEC Strategies for Health in IndiaA
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IEC for Health Programmes in Uttara
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Session 3Private and Public SectorP
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Public-Private Interaction in Healt
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Cost Recovery Measures in Governmen
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Page 142 and 143: Session 1Session 4Health Financing
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Page 160 and 161: Session 1Session 4Access to Health
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Page 182 and 183: HIV/AIDS: International Perspective
Page 188 and 189: HIV/AIDS in India and UttaranchalSe
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Page 192 and 193: HIV/AIDS in India and Uttaranchalpr
Page 198 and 199: Tuberculosis Control Efforts in Ind
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Page 210 and 211: Care of the ElderlySocial care is u
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Streamlining the Drug Procurement a
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Sanitation and Public Health Issues
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Ayurveda and Unani Department and t
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Specific Health Policy and Programm
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