[Draft] Trainers' Guide for Program Manager's course

Introduction

The purpose of this document is to provide the course coordinators and trainers for the ‘Course for Program Managers in NTEP’ guidance for planning and executing the training. The targeted trainees for this course would be:

District Program Managers- District TB Officer (DTO)

State Program Managers- State TB Officer (STO)

This training may be provided by utilizing the blended approach where a mix of training methods and modes will be used to deliver content. This would include either in-person/ virtual training or facilitator led/ Self learning/ demonstration and role plays. Training sessions which require hands-on training will be conducted only in a physical setting. Keeping in mind the aforesaid best practices of the Modernized Training System, the training institute may decide to choose the approach which is most suitable for their trainees.

The training of DTOs is to be conducted at National Institutes (NITRD/NTI) or at select STDCs across country as decided by Central TB Division. The training of STOs is however be conducted at the national Institutes only.

The batch size for Physical Session/Virtual Sessions should not be more than 25.

Virtual sessions: the trainees will be going through the online content, and attempt quizzes after each module. An instructor-led session will also be conducted for each module. This will help the trainees for better clarification of contents and to address the queries and doubts.

Physical/In-person Sessions: For the training areas which require hand-holding of trainees like demonstration of processes- like patient management in Ni-kshay, filling of various forms, Adherence Management tools, recording information on Public Health action, use of NI-kshay Aushadhi, etc in-person training sessions need to be conducted.

The training course content has 14 modules and 61 chapters. Based on different modalities used for the training, the training delivery should take at least 80 hours.

For the purpose of assessment of trainees, a pre-test before the beginning of training, interim quizzes at the end of each module and a post-test at the end of training has been configured in the course content.

Some exercises have also been formulated to assess and reinforce the learnings of the trainees based on their job requirements. These exercise will be communicated to the trainees either before the beginning of in-person sessions and the solutions of which will be discussed during the physical sessions.
The other exercises will be given to trainees during the conduct of the training and will be discussed simultaneously.

The certificates are auto-generated for the trainees in their LMS account on successful completion of post-test and their performance in interim quizzes.

Training curriculum / Agenda

Sr.

Module

Chapters

Training Modality

Duration

(Hrs)

Basics of TB and NTEP

TB & TB Epidemiology
NTEP
Approaches to S&M in NTEP
Integration of NTEP with Health System
Information Systems in NTEP

Self-Reading/Virtual

TB Laboratories and Diagnostic technologies in NTEP

Diagnostic Technologies and Lab Network
TB Detection centres
QA of TDC

Physical

6 (including Lab/Field visit)

TB Diagnosis and Case finding

TB Diagnosis and Case finding
General Concepts in TB Case Finding
Specimen collection and transportation
Approaches to TB Case Finding
Diagnostic Algorithms in NTEP
Active Case Finding Campaign
S&M for Case finding activities in NTEP

Physical

TB Treatment

Anti-TB Drug Formulations and regimens
ADRs to ATT
DS-TB Treatment and Care
Treatment Initiation
Treatment and post-treatment follow up
Treatment Support
Adherence Management

Physical

10(including field visit)

TB and comorbidity management

National Programme for Prevention and Control of Cancer, Diabetes, Cardiovascular diseases and Stroke [NPCDCS]
TB and HIV
TB and Diabetes
TB and malnourishment
TB and Substance Abuse
TB and other comorbid conditions

Physical

Public Health Action

Patient Support
Contact tracing and investigation
Counselling
TB Arogya Sathi App

Physical

TB Prevention

Physical

Direct Benefit Transfer in NTEP

General Concepts in DBT
Processes in DBT
Monitoring of DBT

Physical

Financial management and Planning

Overview of PIP
Needs assessment for Planning.
Preparing a PIP
Implementing the Plan
Financial expenditure and accounting

Physical

Procurement, Supply Chain Management & Preventive Maintenance

General Concepts in SCM
Information system for SCM in NTEP
Processes in SCM
Procurement in NTEP
QA in SCM

Physical

Partnerships, Corporate and Multisectoral engagement

General concepts in Partnership and MSE
Models of Partnership
Establishing Partnership
Multisectoral Engagement
Medical Colleges and NTEP

Physical

ACSM and Community Engagement

ACSM
ACSM Activities
Social Inclusion and wellness activities
Community Engagement
PM TB Mukt Bharat Campaign

Physical

Supervision, Monitoring and Evaluation

Supervision

Monitoring

Programme Monitoring and Reviews

Physical

Training and capacity development

Physical

Trainers

For this course, following personnel may be appointed as the trainers:

National trainers from National Institutes

National Consultants- Central TB Division

Trainers from select STDCs (identified by Central TB Division)

Select WHO consultants (from States)

Consultants (partner Organisations)

Eligibility

Trainers are selected based on their ability to conduct training in an interactive and interesting manner. The Trainers should have completed the ‘Course for Program Managers’ and they must possess strong knowledge about the NTEP and the various processes related to patient workflow, Ni-ksahay and Ni-kshay Aushadhi. The Trainers need to go through the Chapter- wise Training Guide for this Course, provided as an Annexure.

The Trainers should be well versed with the IT systems such as, Zoom (for video conferencing), Swasthya-eGurukul (Learning Management System), Ni-kshay and Ni-kshay Aushadhi.

Chapter wise detailed instructions for Trainers

The aim of providing chapter-wise detailed instructions provides the Trainers with the following:

Module-wise and Chapter-wise, modality that may be adopted (Self-reading/virtual/ Physical/ In-person)

The estimated time to complete the content.

The key messages that a trainer should emphasize upon, while delivering the training

The activities which should be conducted at the end of each chapter / session to ensure learning effectiveness. This may include asking specific questions, demonstrating processes, discussing various forms and equipment. If any Module specific physical visits are required to be conducted, such details are also provided here.

Some exercises have also been provided with the relevant chapters that the trainees need to finish as the part of curriculum. The trainers should ensure that all the trainees finish these exercises individually and record it in appropriate response forms. All the exercise should be discussed by the trainers during the training.

This guiding document will also aid in bringing uniformity with respect to the content and quality of training conducted across the entire state and nation.

Module 1: Basics of TB and NTEP Virtual Session (4 hours)
Chapter 1.1	TB & TB Epidemiology	Virtual Session (60 min)
Emphasis Points	1. Difference between Incidence and notification 2. Difference between Exposure to TB, infection and TB disease.
Post Session Activity	Give an exercise to calculate the Notification rate of a TU. In a TU with a population of 2 lakhs, 100 TB cases were diagnosed and reported during the year 2022. A total of 90 people with TB were initiated on treatment, 5 died and 2 migrated before initiation of treatment and 3 could not be contacted at all. What is the annual TB notification rate for that TU in 2022? [ Answer: 50 per lakh] Discuss - Can we call the above obtained Notification figure as the incidence of TB in that TU? If not, Why? [Discussion Points: Notification and Incidence are not the same. Notification includes all diagnosed TB cases and reported to the system. It includes both new and previously treated cases. There may be cases diagnosed, but not reported. It is possible that there will be cases in the community not diagnosed at all.] These exercises are to be given as assignments that trainees need to finish before start of 2nd module. Assignments: 1.1.1-Find the incidence of TB in India in preceding year. Please mention the source also. 1.1.2-What was the no of TB notifications in India for year 2021. Please mention the source that you used. Why incidence is not same as notification? 1.1.3-Download the notification register (Q1-2023) of your district. 1.1.4-What are the Columns headings available in the register? 1.1.5-What are the options available under the filters for the 4 columns- a) patient status, b) key population, c)basisOfDiagnosis_FinalInterpretation, d) Treatment Outcome
Chapter 1.2	NTEP	Virtual Session (45 min)
Emphasis Points	Explain what India is committed to achieve in 2025 in relation to SDG related to ending TB. Clarify that the country has preponed the 2030 SDG targets related to ending TB to 2025. Organizational structure of NTEP with broad functions of each institution (state level and below) Different stages in the patient’s life cycle need to be explained in detail and emphasis on the concept of continuum of care from ‘presumptive TB to post treatment follow up'. Concepts of ‘’Standards of TB Care’’ as a minimum set of care that every citizen in India should receive irrespective of where he/she seeks care from. What does a TU actually mean?
Post Session Activity	Discuss- ‘What India is committed to achieve in 2025 in relation to ending TB?’’ [Clarify that the country is only trying to achieve the SDG goals related to Ending TB] Discuss- ‘Can Medical College be a PHI?’ Assignments: 1.2.1-Enumerate the 4 pillars/strategies mentioned in NSP (2017-2025). 1.2.2-Elaboorate the build component with respect to your district.
Chapter 1.3	Integration of NTEP with Health System	Virtual Session(30 mins)
Emphasis Points	Need for integration of NTEP with the general health system & NHM and how that integration is envisioned .
Post Session Activity	Discuss - "What are the opportunities available to NTEP through Health & Wellness Centers? How could that be materialized”’
Module 2	TB Diagnosis and Case Finding	Virtual Session (4 hours)
Chapter 2.1	Diagnostic Technologies	Virtual Session (30 min)
Emphasis Points	Names of different tests,their uses, advantages and disadvantages
Post Session Activity	Ask what are the advantages and disadvantages of FL- LPA over NAAT?
Chapter 2.2	Diagnostic Network & Hierarchy	Virtual Session (30 min)
Emphasis Points	Network and hierarchy of laboratories and their basic role
Post Session Activity	Ask “ how many sputum collection and transportation facilities are there in their concerned TU? Make one participant explain how it functions and what are the benefits out of it”?- Bring out the following benefits (1) prevents leaks in cascade of care (reduce loss from presumptive TB identification to TB Testing) (2) minimizes patient inconveniences (3) minimize patient Turnaround Time (4) reduce out of pocket expenditure (5) helps in infection control as people with symptoms need not travel

Chapter 2.3	Approaches to TB Case Finding	Virtual Session (30 min)
Emphasis Points	Differentiate between screening and testing. The three approaches may be discussed by giving suitable examples to fit into the three scenarios
Post Session Activity	Discuss the following scenarios and ask the participants which case finding those are (i) Screening for active TB in a Diabetic Clinic & testing those who screened positive (ii) Screening for active TB in an elderly home & testing those who screened positive (iii) Screening for active TB in cancer wards & testing those who screened positive
Chapter 2.4	TB Case Finding in NTEP	Virtual Session (30 min)
Emphasis Points	Diagnostic algorithm for Pulmonary TB- Role of Chest X ray as a screening tool and the need to complete the diagnostic algorithm. Classification of TB on the basis of site,diagnosis, drug resistance
Post Session Activity	Discuss: “What proportion of presumptive TB patients in your TU completes the diagnostic algorithm? What are the implications if the people are not completing the diagnostic algorithm?”
Chapter 2.5	Active Case Finding Campaign	Virtual Session(45 mins)
Emphasis Points	Step by step process in planning and execution of an ACF campaign with special emphasis on identification of target population, need for micro planning and need to prevent the leaks in the cascade of care.
Post Session Activity	Discuss how they monitor the ACF in their TU against ‘Cascade of Care? What are the measures they undertake to prevent the leaks in ‘’Cascade of care’’?
Module 3:	TB Treatment and care	Virtual Session (4 hours)
Chapter 3.1	General Concepts in TB Treatment	Virtual Session (60 mins)
Emphasis Points	It's an overview chapter explaining the concepts- Fixed Dose Combination, Intensive & Continuation Phase. Process of Treatment Initiation and Transfer of patients
Post Session Activity	Request two participants to demonstrate in Demo Ni-kshay the ‘Transfer’ of patients using (i) Push and (ii) Pull methods.
Chapter 3.2	DS-TB Treatment and Care	Virtual Session ( 30 mins)
Emphasis Points	Regimen and dose of drugs for managing DS-TB for adults and pediatric group and weight bands available Display all FDCs in NTEP and ensure the participants could identify all information related to it Common adverse events of anti-TB drugs
Post Session Activity	Call one participant and ask to explain the step by step process for initiating treatment to a 50 Kg old adult diagnosed with pulmonary TB (Rif Sensitive). Write down all the steps in a flip chart/chatbox/Virtual whiteboard. Ask other members to comment on the missed steps and the order of steps. Call a second participant and ask to explain the follow up for the same patient.
Chapter 3.3	DR-TB Treatment and care	Virtual Session (30 mins)
Emphasis Points	What is UDST? Classification of DR-TB? Regimens available for DR-TB? Levels of facilities where treatment needs to be initiated.
Post Session Activity	Ask participants for doubts and help them clear those doubts.

Chapter 3.4	Different DR-TB Regimens	Virtual Session (15 mins)
Emphasis points	Different regimens, constituents and duration ADRs due to different regimens	Virtual Session (15 mins)
Chapter 3.4	TB Infection treatment and care	Virtual Session (30 min)
Emphasis Points	Eligible people for TPT Testing for TPT Steps for Ruling out active TB before initiating TPT Adherence monitoring and treatment support for those on TPT
Post Session Activity	Role Play- Counseling for TPT
Chapter 3.5	TB Co-morbidity and special situations	Virtual Session (30 min)
Emphasis Points	Bidirectional screening for TB-HIV, TB-Diabetes Need for screening for tobacco and alcohol use among people with TB Nutritional assessment for people with TB. Need for and mechanism of Linkages of people with comorbidity (HIV, Diabetes, Malnutrition, Tobacco and alcoholism)
Post Session Activity	Ask the participants to describe the existing mechanism at their TU to screen TB among the people visiting ICTC centers - how is the screening being done? How is it ensured that all those referred for testing have undergone testing? Discuss if there is any scope for improvement. Ask the participant to describe how diabetes testing is done among people with TB in their TU? What are the steps if a person with TB is found to have diabetes? Who and how is diabetic control ensured for that person? Discuss if there are any ways to improve.
Module 4:	Adherence Management	Physical Session (4 hours)
Chapter 4.1	Patient Management	Virtual Session (60 mins)
Emphasis Points	How the information of patients is managed through Ni-kshay (Enrollment, Request for Test).
Post Activity Session	Call two participants to demonstrate how they (1) enroll a subject and (2) request for Test in Ni-kshay Make all participants to view their task list in Ni-kshay and discuss how they are going to use the feature
Chapter 4.2	General concepts in Adherence management	Physical Session (60 mins)
Emphasis Points	This is an overview chapter where participants need to understand the (i) General Concepts in Adherence Management such as why adherence monitoring and treatment support is important, (ii) what are the various supports required by a person with TB during TB treatment and (iii) various ways of providing those supports and (iv) various ways to monitor treatment adherence?
Post Session Activity	Ask one participant to demonstrate how they register treatment supporter in Ni-kshay
Chapter 4.3	Adherence Support	Physical Session (60 mins)
Emphasis Points	Imparting skills to Record adherence in Ni-kshay- Demonstrate the recording of adherence in Ni-kshay. Recording adherence using TB Arogya Sathi Application
Post Session Activity	Call one participant and ask to demonstrate recording adherence using TB Arogya Sathi Application
Chapter 4.4	Chapter: 99 DOTS	Physical Session (30 mins)
Emphasis Points	Need to have 99 DOTS Envelops for this sessions. Explain step by step process of adherence monitoring using 99 DOTS (Choosing the envelope, educating the person with TB on 99DOTS, linking it with Ni-kshay, administering the first dose, troubleshooting)
Post Session Activity	Give the following scenarios and ask them to troubleshoot\ Scenario 1: One of their patients complained that she used to dial the toll-free number every day and used to hear “Thank You” also. But when you check, the Nikshay dashboard is still showing red. Scenario 2: One of your clients with TB called you and told you that his call is not going to the ‘toll free’ number because of ‘insufficient’ balance.
Chapter 4.5	Chapter: MERM	Physical Session (30 mins)
	Need to have a MERM device for demonstration. Battery assembly may be explained and the different scenarios to troubleshoot should be explained. The process flow in Ni-kshay(registering the device, setting the alarm and refill time) should be explained to the participants.
	One/more participants may be asked to demonstrate this in Ni-kshay(Demo)
Chapter 4.6	Chapter: Monitoring of adherence	Physical Session (60 mins)
Emphasis Points	Participants need to be empowered to use adherence summary dashboards and interpret the indicators.
Post Session Activity	Request everybody to open their adherence dashboards and comment on their % of 'Average Adherence' of all patients on treatment. Request all participants to open their adherence task list and ask their plans based on the task list
Module 5:	Public Health Action	Physical Session (4 hours)
Chapter 5.1	Patient Support	Physical Session (60 min)
Emphasis Points	Various kinds of support the TB patient needs (nutritional support, psycho social support, support for deaddiction, travel support) and how STS could help in offering the same
Post Session Activity	Give a scenario: A 62 year old woman from a Tribal community affected with TB. Ask all participants to list out all the Government schemes/initiatives which can support her during the treatment period? Write down all schemes in a flip chart/Chatbox/Virtual board
Chapter 5.3	Contact Investigation	Physical Session (60 mins)
Emphasis Points	Step by step process for contact investigations Discuss the steps to record the contact tracing in Ni-kshay
Post Session Activity	Ask one of the participants how contact investigations are happening in his/her TU (Coverage, Quality, Periodicity, Challenges). Ask one/more participants to demonstrate the process in Ni-kshay(Demo)
Chapter 5.4	Counselling and Education	Physical Session (60 mins)
Emphasis Points	Basic principles of counselling (DOs and DONTs) Points to be included while counselling of a person with TB
Post Session Activity	Ask participants to comment on the following statements made by STS while counselling a person with TB “I have already informed all people who came to your shop that you are having TB”. (Clue: It's a breach of confidentiality. It should have been discussed with the person with TB first. The person with TB should have been empowered to disclose it to others if required) “If you are not taking the medicines properly, you will definitely die”. (Clue: It's a coercive/threatening language and should be avoided) “Because you were a smoker and alcoholic, you got TB” (Clue: It's a blame on the person and should be avoided)
Module 6:	DBT	Physical Session (4 hours)
Chapter 6.1	General Concepts in DBT	60 mins
Emphasis Points	This is an overview chapter. Various DBT schemes for people affected with TB Various stakeholders while processing DBT (Beneficiary, Maker, Checker) PFMS
Post Session Activity	Re-emphasise the concepts - Maker & Checker; Ni-kshay & PFMS.
Chapter 6.2	Processes in DBT	150 mins
Emphasis Points	Explain beneficiary registration, benefit process & benefit approval. Processing incentives for NP, private provider, treatment supporter, tribal TB Calculation of benefits DBT reports & registers in Ni-kshay
Post Session Activity	Make every participant open their DBT benefit register and beneficiary register and comment on performance.
Module 7	Supervision, Monitoring & Evaluation	Physical (4 hours)
Chapter 7.1	Supervision	60 minutes
Emphasis Points	General Concepts of Supervision and basis tenants of a good supervisory process Supervisory Protocols for STS Supervisory roles of MO-TC & DTO at TU
Post Session Activity	Reemphasise the concept of supportive supervision. Get feedback on how some of them plan to change their supervision plan.
Chapter 7.2	Program Monitoring Indicators	120 minutes
Emphasis Points	Nine program monitoring indicators - definitions, how to calculate the indicators, how to interpret the indicators. How to perform a root cause analysis- (1) drill down to the problem using data, (2) perform a person, place, time analysis, (3) explore for potential reasons of low performance through interviews.
Post Session Activity	Assignment: Each participant needs to calculate any 3 indicators in their TU based on real time data and interpret those indicators. For one of the low performing indicators, they need to do a root cause analysis and come up with potential solutions. Every participant needs to submit an assignment based on this.
Module 8	Supply Chain Management	Physical (4 hours)
Chapter 8.1	General Concepts	60 mins
Emphasis Points	General Concepts of SCM Principles of SCM Drug distribution flow Nikshay Aushadhi
Post Session Activity	Ask for any doubts from the participants and clarify the same.
Chapter 8.2	Stocking Norms	30 mins
Emphasis Points	Buffer stocks and storage norms
Post Session Activity	Reinforce the concepts of buffer stock and storage norms.
Chapter 8.3	Supply chain process	150 mins
Emphasis Points	Indenting, Receipt Storage of drugs
Post Session Activity	Request one participant to demonstrate drug indenting through Ni-kshay aushadhi
Chapter 8.4	Drug dispensation Module	30 mins
Emphasis Points	Dispensation of drug using Ni-kshay, adding filling and returning dispensation
Post Session Activity	Request one participant to demonstrate the Ni-kshay dispensation module.
Module 9	Multisectoral Sector Engagement	Virtual (2 hours)
Chapter 9.1	General Concepts	30 mins
Emphasis Points	Why private sector engagement is important and what is the Vision of NTEP on private sector engagement.
Post Session Activity	Recollect Standards of TB Care in India and emphasize that the vision of NTEP with regard to private sector engagement is to ensure STCI to all patients. The choice of where to take treatment remains with the patient. Emphasize that more than the private sector, it is the NTEP who wants to engage with the private sector to ensure that all patients reaching them receive STCI. Tell that TU is a population and ensuring STCI to all cases emerging from that population is the responsibility of STS. STS can engage the private sector to minimize his/her workload.
Chapter 9.2	Models of Private Sector Engagement	60 mins
Emphasis Points	Explain PPSAs, Direct Option for engagement. Explain STEPS
Post Session Activity	Ask each of the participants to think what model suits for private sector engagement in their TU and why.
Chapter 9.3	Partnership Guidelines	30 mins
Emphasis Points	Emphasis on various options under partnership options
Post Session Activity	Discuss what all partnership options are currently existing in their TUs and what would they want to have.
Chapter 9.4	Regulations	30 mins
Emphasis Points	Regulations of Mandatory TB Notification and Schedule H1
Post Session Activity	Discuss how information from schedule H1 could be used? (Clue: Most crucial field in the schedule H1 register is the name of the provider who prescribed it. Information from Schedule H1 register could be used to Identify the provider prescribing the anti TB drugs and prioritize for engagement, Identify missing TB cases)
Module 10	ACSM and Community Engagement	Physical (3 hours)
Chapter 10.1	General Concepts in ACSM	60 mins
Emphasis Points	Differentiate clearly among Advocacy, Communication and Social Mobilization Common approaches for ACSM for TB Elimination
Post Session Activity
Chapter 10.3	Protocols for ACSM activities	60 mins
Emphasis Points	Organising Community Meetings, Peer group interventions, ACSM activities in schools
Post Session Activity	Discuss experiences form 1-2 participants regarding organizing community meetings
Chapter 10.4	Community Engagement	60 mins
Emphasis Points	LSGs and their role in TB Elimination TB Forums and what they can do What role can TB Champions play?
Post Session Activity	Discuss what needs to be done to reduce stigma regarding TB in the community. Encourage everybody to discuss.

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[Draft] Trainers' Guide for Program Manager's course

[Draft] Trainers' Guide for Program Manager's course