Assessment of TB Care and Management Services in Tibetan Settlements in India

Disclaimer: The Global Health Bureau, Office of Health, Infectious Disease and Nutrition (HIDN), US Agency for International Development,
financially supports this material through Challenge TB under the terms of Agreement No. AIDOAA-A-14-00029. This material is made
possible by the generous support of the American people through the United States Agency for International Development (USAID).
The contents are the responsibility of Challenge TB and do not necessarily reflect the views of USAID or the United States Government.

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Assessment of
TB Care and
Management Services
in Tibetan Settlements
in India

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Tibetan Assessment Report
DETAILS OF THE ASSESSMENT INVESTIGATORS,
FUNDERS AND PARTNERS
Assessment Title Assessment of TB care and management services of Tibetan settlements in India
Project Challenge TB
Assessment Investigators Dr Jamhoih Tonsing; Ms Kavita Ayyagari; Dr Anupama Hazarika; Dr Neerja Arora; Dr Lopamudra Paul; Dr
Jaya Prasad Tripathy; Dr Ajay MV Kumar
Funding Source(s) USAID
Assessment Partners Government of India Central Tuberculosis Division (CTD): Dr S Khaparde and Dr KS Sachdeva;
Department of Health, Central Tibetan Administration (DoH – CTA): Dr Lobsang Tsering and
Dr Tsering Wangchuk; The Tibet Fund: Dr Vikas Dagur and Mr Bob Ank; USAID India: Dr Reuben
Swamickan
Research Site(s) Across India (Tibetan settlements in three states: Himachal Pradesh, Uttarakhand and Karnataka)
Assessment Duration One year (May 2015-April 2016)

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Acronyms..............................................................................................................................................................................5
Executive Summary.............................................................................................................................................................6
Chapter 1: Background.......................................................................................................................................................20
1.1 Demographic profile of the Tibetan settlements in India.........................................................................................20
1.2 Overview of the Central Tibetan Administration and the Tibetan Health System...................................................10
1.3 Burden of TB among Tibetans in exile in India.......................................................................................................13
Chapter 2. Methods and Materials......................................................................................................................................15
Goal................................................................................................................................................................................15
Objectives.......................................................................................................................................................................15
Methodology ..................................................................................................................................................................15
Assessment Design.........................................................................................................................................................15
Assessment Sites ............................................................................................................................................................15
Assessment Population...................................................................................................................................................17
Sample Size ..............................................................................................................................................................17
Study Method.................................................................................................................................................................19
Quantitative method .................................................................................................................................................19
Qualitative method ...................................................................................................................................................20
Data Management .........................................................................................................................................................22
Data collection .........................................................................................................................................................22
Data Confidentiality .................................................................................................................................................23
Data Analysis Plan .........................................................................................................................................................23
Informed written consent ...............................................................................................................................................24
Chapter 3. Governance and Programme Management.......................................................................................................25
3.1 Tuberculosis Programme Management and Governance.........................................................................................25
CONTENTS

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Chapter 4. Assessment of service delivery...........................................................................................................................1
4.1 Tuberculosis Service Delivery at DoH Facilities and Delek Hospital .......................................................................1
4.2 Men-Tsee-KhanTibetan Medical College and health centres ..................................................................................11
4.3 School Health Centres..............................................................................................................................................13
4.4 Health Facilities managed by Tibetan Monasteries..................................................................................................16
4.5 Private Doctors and Private Chemists......................................................................................................................18
4.6 RNTCP perspective..................................................................................................................................................20
Chapter 5. Analysis of Routine Health Management Information System data.................................................................24
Chapter 6. Analysis of self-reported data from Tibetan Health Facilities..........................................................................26
6.1 Analysis of TB diagnostic services at 7 Major Hospitals...........................................................................................1
6.2 Analysis of TB treatment Services at 7 Hospitals......................................................................................................3
6.4 Analysis of General Information about 7 Hospitals.................................................................................................15
6.5 Analysis of data from Tibetan Primary Health Centres............................................................................................17
6.6 Analysis of Data received from Health Clinics..........................................................................................................2
6.7 Analysis of Data from Health Facilities at Tibetan Schools.......................................................................................4
Chapter 7. Community Perspectives ....................................................................................................................................1
Chapter 8. Recommendations...............................................................................................................................................1
Annexure 1. Details of interviews and health facilities visited ............................................................................................7
Annexure 2. Diagnostic and Treatment Protocols at Delek Hospital ...............................................................................116
Annexure 3. Directory of Tibetan Health Facilities in India and Nepal...........................................................................120
Annexure 4. Directory of Tibetan Hospitals, PHCs and Health Clinics...........................................................................121
Annexure 5. Directory of School Health Clinics..............................................................................................................123
Annexure 6. Contact Details of Men-Tsee-KhanCentres .................................................................................................125
References.........................................................................................................................................................................127

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ACF Active Case-Finding
ART Antiretroviral Therapy
ASHA Accredited Social Health Activist
BMW Bio-Medical Waste
C&DST Culture and Drug-Susceptibility Testing
CBNAAT Cartridge Based Nucleic Acid Amplification Testing
CTA Central Tibetan Administration
CTD Central TB Division, Government of India
DoH Department of Health
DoE Department of Education
DoR Department of Religion
DOT Directly Observed Treatment
DOTS Directly Observed Therapy, Short Course
DS-TB Drug-Sensitive TB
DR-TB Drug-Resistant TB
DST Drug-Susceptibility Testing
EQA External Quality Assessment
FGD Focus Group Discussion
HIV Human Immunodeficiency Virus
IEC Information Education and Communication
KII Key Informant Interview
MDR-TB Multidrug-Resistant Tuberculosis
MTB Mycobacterium Tuberculosis
OPD Out-Patient Department
PMDT Programmatic Management of Drug-Resistant Tuberculosis
RNTCP Revised National Tuberculosis Control Programme
SOP Standard Operating Procedures
STO State TB Officer, RNTCP
TB Tuberculosis
ACRONYMS

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TMS Traditional Medicine System
TVHA Tibetan Voluntary Health Association
The Union The International Union against Tuberculosis and Lung Diseases
USAID United States Agency for International Development
WHO World Health Organization
XDR-TB Extensively Drug-Resistant Tuberculosis

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EXECUTIVE SUMMARY
their perspectives and practices related to TB. Information
was also gathered through self-reporting questionnaires
sent out to all Tibetan health facilities specifically for this
assessment.
In addition, the report draws on existing information shared
by colleagues from the Tibetan DoH as well as The Tibet
Fund, particularly general information about the Tibetan
diaspora in India, its governance as it relates to health, data
from the health information system (HIS) and active case-
finding for TB.
KEY FINDINGS
BACKGROUND INFORMATION: TIBETAN REFUGEES
AND THEIR HEALTHCARE FACILITIES1
™ The Central Tibetan Administration (CTA) was
established by His Holiness The Dalai Lama in
1959, shortly after his exile from Tibet. The CTA
is headquartered in McLeod Ganj, Dharamshala,
Himachal Pradesh, India. In addition to political
advocacy, it administers a network of health facilities,
schools, monasteries and nunneries, as well as
settlements through various departments of the CTA.
™ The total population of the Tibetan diaspora living
in India is estimated to be 94,200. The population is
spread across 39 settlements and sub-settlements in
several states of India, with almost 48 percent of the
population residing in five of the largest settlements:
Dharamshala, Doeguling (Mundgod), Lugsam
(Bylakuppe), Dekyilling and Ladakh.
™ About 53.5 percent of Tibetan refugees in India live in
congregate settings consisting of 60 monasteries and
nunneries, 63 schools, which are both day schools and
residential schools, and four youth hostels.
™ The Tibetan DoH was formally established in 1981,
The assessment of tuberculosis (TB) care and management
services among Tibetan settlements in India was
conducted by The Union as a part of the United States
Agency for International Development (USAID)–funded
Challenge TB India project. The scope of the assessment,
initially planned for a rapid assessment, was expanded
per suggestions received from the Department of Health
(DoH) of the Central Tibetan Administration (CTA), the
Central TB Division (CTD) of the Government of India,
The Tibet Fund and USAID India.
The assessment took place in two phases: (1) a scoping
visit to meet with the officials to better understand the
overall Tibetan healthcare system, including for TB and
to collect existing data, and (2) a more detailed assessment
of TB care and prevention activities, including visits
to additional sites, to have a better representation of the
Tibetan settlements across India. The protocol for the
detailed assessment was developed with input from the
CTD, Tibetan DoH, The Tibet Fund, USAID and learnings
during the scoping visit. The Union’s Ethical Approval
Group approved the protocol.
The team visited four hospitals, one primary health centre,
and one health centre, all of which are part of the Tibetan
DoH network; three hospitals, one monastery health centre,
and six school health centres that fall under the management
of the Tibetan Department of Religion or Department of
Education; the Tibetan Medical and Astrological Institute
and three Men-Tsee-Khang traditional Tibetan medicine
clinics. Interviews were carried out with key personnel
from the Tibetan Department of Health, Religion and
Education, Revised National Tuberculosis Control
Programme (RNTCP) officials at the centre, state and
district levels, and private practitioners at the field visit
sites. In-depth interviews and focus-group discussions
were conducted with community members to understand
1
Planning Commission Central Tibetan Administration (2009). Demographic Survey of Tibetans in exile-2009. (TDS 09)

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in order to maintain the health and well-being of
the Tibetan diaspora. It is registered as the Tibetan
Voluntary HealthAssociation (TVHA) under the Indian
Society Registration Act, working for basic healthcare
needs of Tibetan refugees.
™ The DoH operates through a network of 39 health
facilities in India: seven hospitals, six primary
healthcare centres and 26 health clinics.All these health
facilities form independent reporting units, reporting
directly to the DoH. In addition, the Delek Hospital
and the Tibetan Medical and Astrological Institute,
both located in Dharamshala, are the main autonomous
health centres under the CTA.
™ Each hospital provides health services to a population
of 5,000-16,000 and is equipped with all basic TB
diagnostic and treatment facilities including TB
wards. Primary health centres serve settlements with
populations ranging from 1,000-7,500 and are staffed
with either resident or visiting doctors, staff nurses
and community health workers. Health clinics cater
to small populations and are staffed with community
health workers with a doctor visiting once every week
or two weeks.
™ There is a health committee at each settlement headed
by the settlement officer which works to improve
community healthcare services. The settlements
comprise 1,000-8,000 people and are divided into
camps, also called villages. The settlement officer is the
keycoordinatingofficerlinkingthevariousdepartments
of the CTA and is in charge of development, welfare
and health issues.
™ In addition to the above, there are health facilities
catering to monks and nuns and independently managed
by several monasteries and nunneries and facilities
catering to the school children and staff of schools,
which are managed by the Department of Education.
These health facilities are independently staffed and
there is no formalised referral and reporting system
among these health facilities and the DoH.
BACKGROUND INFORMATION:
TB BURDEN AMONG TIBETANS IN EXILE
™ Within the Tibetan DoH, TB is widely recognised
as one of the biggest public health problems among
Tibetan refugees. Several reports indicate a much
higher incidence of TB among Tibetans compared
to the local native population. The DoH reported an
annual incidence rate ranging from 772 to 857 per
100,000 persons in three different settlements in 2008.
In the same year, the incidence rate among Tibetan
refugees in Himachal Pradesh was estimated to be
816 per 100,000 compared to 168 per 100,000 among
the local Indian population, a fivefold higher rate was
reported amongst Tibetan populations.
™ Multidrug-resistant TB (MDR-TB) rates are also much
higher among this population. According to a survey
conducted by the DoH and Delek Hospital in 2010,
MDR-TB rates of 14.5 percent among new TB cases
and 32.4 percent among retreatment TB cases were
found. This is substantially higher compared to the
MDR-TB rates among the general population in India,
which is estimated by the World Health Organisation
(WHO) to be 2.2 percent among new and 15 percent
among retreatment TB cases (WHO TB Report 2014).
TB PROGRAMME: OBSERVATIONS DURING FIELD VISITS
™ The TB Control Program is one of the priority
disease control programmes run by the DoH.
However, a dedicated central unit with clear roles
and responsibilities to plan, implement and monitor
the TB programme is lacking. Key documents such
as a strategic plan (preferably costed), guidelines and
standard operating procedures (SOPs), and training
plans for building capacity of staff are not available
or are inadequate. While guidelines of the RNTCP are
used and several staff members have been trained by
the RNTCP programme, there is a need to supplement
that, as some practices differ and the organisation of
services is different from the RNTCP.
™ Delek Hospital functions as a nodal centre for training
of doctors, nurses and lab technicians working in
other Tibetan health establishments, including DoH
hospitals, primary health centres and health clinics, as
well as health staff from schools and monasteries. In
addition, few doctors and lab technicians have received
modular training organised by RNTCP.
™ Standardised recording and reporting forms are available,
and quarterly reports are reported to be prepared and
submitted regularly. An Epi Info–based data entry
system is being introduced at the hospitals, which also
gives dashboard functionality for easy data compilation
and analysis at the local level. At some of the sites
visited, some registers and forms were not available;
however, Excel sheets with patient-wise data were being
maintained and sent to DoH on a quarterly basis.
™ Staff from peripheral heath facilities already consult
with doctors from the DoH and Delek Hospital or refer
cases; thus there is a need for such support. Regular
and formalised supervision and monitoring as well as
annual review meetings will provide an opportunity for
on-the-job training and support to resolve challenges
in the field.

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Executive Summary
™ There is currently no mechanism for central purchase
of drugs and consumables. The health facilities
procure all lab supplies and anti-TB drugs from the
local market from well-reputed companies. At the
hospitals visited, drug stocks were managed very well
using computerised software and stored properly.
Previous attempts to centralise procurement were not
operationally feasible due to difficulties in distributing
stock to the widely scattered health facilities, often in
remote locations.
™ There is some level of coordination with the RNTCP,
largely guided by relationships at the local health
facility level. Some Tibetan health facilities have been
identified as designated microscopy centres as well
as directly observed treatment (DOT) centres by the
RNTCP and receive RNTCP drugs and participate
in the external quality assessment (EQA) system for
sputum microscopy. Conversely, Delek Hospital
in Dharamshala caters to both Tibetan and local
populations, including those referred by the local
RNTCP programme for in-patient management.
™ The DoH provides financial assistance to patients who
cannot afford to pay for TB treatment. The quantum of
such assistance varies from person to person depending
on their economic situation. The patient buys the drugs
for one month at a time from the hospital pharmacy at
cost price. Generally, 75 percent of the cost for first-
line drugs and 25 percent to 100 percent of the cost of
second-line drugs is refunded.
™ Documents compiled as a part of this assessment are
found in the annexures and include: (1) a settlement-
wise list of health facilities, (2) a directory of DoH
hospitals, primary health centres and health clinics,
(3) a list of school health facilities and (4) a directory
of Men-Tsee-Khang clinics. These could be used for
mapping, planning and management of services,
including linkages with the RNTCP network for
collaborative work and capacity building.
TB SERVICES IN TIBETAN HEATH FACILITIES:
OBSERVATIONS DURING FIELD VISITS
™ TB care is provided by doctors and designated nurses
along with lab technicians, pharmacists and X-ray
technicians at the four hospitals visited: Doeguling
Tibetan Resettlement Hospital, Mundgod; Tso-Jhe
Khangser Hospital, Bylakuppe; Dekylling Hospital,
Dehradun; Delek Hospital, Dharamshala. In Mundgod,
there was no doctor at the time of survey and all nurses
were expected to do TB work as part of routine duties. .
™ Doctors and TB nurses have good knowledge of
management of TB per DoH/WHO and RNTCP
guidelines. They are also well aware of points for
which patients should be counselled such as cough
hygiene, nutrition, identification of drug side effects,
and the common drivers and co-morbidities of TB,
such as diabetes, HIV infection, smoking, alcohol,
malnutrition, etc.
™ Delek Hospital in Dharamshala has been providing
exemplary TB care to Tibetan populations as well as
the local population and is well regarded by all.
™ All hospitals visited have binocular microscopes and
provide sputum microscopy and X-ray services. Three
of the larger hospitals have GeneXpert machines and
all four hospitals also have isolation wards for TB
patients. CBNAAT (Cartridge Based Nucleic Acid
Amplification Testing) was not functional at Dekylling
Hospital at the time of the visit. There are no facilities
offering culture and drug-susceptibility testing
(C&DST) services.
™ There is no mechanism for internal quality control or
EQA for sputum microscopy within the DoH system.
Some labs do participate in RNTCP’s EQA system, but
results of the performance were not available. Annual
maintenance of microscopes is not done; however,
most hospitals have spare microscopes. Fluorescence
microscopes were available but not used. Many labs
maintained two registers, one based on the RNTCP and
the other based on its own facility’s requirements.
™ A person with TB symptoms can therefore present to
any of the Tibetan health facilities—DoH hospitals,
primary health centres and health clinics; the network
of Men-Tsee-Khang clinics linked to the Tibetan
Medical and Astrological Institute, or the facilities at
Tibetan schools, monasteries and nunneries. Usually,
presumptive TB cases are referred to health facilities
under the DoH. Outside of the Tibetan system,
presumptive TB patients may also access the services
of the RNTCP and of local private healthcare providers.
™ TB services are also provided through the healthcare
network of the DoH, as well as health facilities
located in several schools, monasteries and nunneries.
The health clinics identify and refer presumptive
TB patients to the primary health centres (if sputum
microscopy and X-ray is available) or directly to the
hospitals. They also provide DOT to patients who are
referred back to the community.
™ Patients are screened for symptoms of cough, fever,
weight loss, and night sweats. All patients presenting
with prolonged cough are subjected to sputum
microscopy and X-ray (when advised by the clinician).
Other lab investigations may be done per the doctor’s
order. All smear positive as well as smear negative,

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X-ray positive patients are referred for GeneXpert tests
wherever available.
™ Patients diagnosed with Rif-resistant TB are referred
for culture and drug-susceptibility testing (C&DST).
Samples are sent to Hinduja Hospital in Mumbai.
Within the DoH system, all drug-resistant TB (DR-TB)
patients are referred to Delek Hospital, where there is
capacity for management of such cases.
™ TB patients are provided daily treatment (2HRZE/6HR)
for six months under DOT. MDR-TB patients are
prescribed individualised treatment based on their DST
profile. The regimen used and the treatment duration
is largely aligned with WHO recommendations,
though follow-up examinations are conducted at more
frequent intervals (single sputum test every week for
drug-susceptible TB patients until sputum conversion)
™ Out-patient and in-patient wards are well-ventilated.
All TB patients are admitted in separate TB wards. TB
isolation rooms are available in the hospitals visited.
In Delek Hospital, which admits DR-TB patients, N95
masks are available for staff and patients, and visitors
are provided with three-layer disposable surgical
masks. The laboratory at Delek Hospital is a closed
room, warranting the need for proper ventilation
when there is a risk of generating aerosols during lab
procedures.
™ Information, education and communications (IEC)
materials on TB are available in both English and
Tibetan and displayed prominently in the hospitals.
™ The DoH has been conducting active case-finding
(ACF), targeting people residing in congregate settings
such as schools. Contact tracing is also done routinely
for index cases diagnosed in schools, monasteries
and nunneries. According to data shared by DoH, in
2012, there were 99 TB cases among 15,404 students
(prevalence=643 cases/100,000 students). In 2013,
there were 103 TB cases among 13,741 students
(Prevalence =749 cases/100,000 students), of which
23 cases (22%) were identified on the basis of ACF.
In 2014, 12 TB cases were discovered among 13,056
students on the basis of ACF.
™ The occupations of patients among the TB cases
registered in the health information system was made
available to the team. Of the total 1,080 TB patients
registered in the seven hospitals surveyed, in the period
2012-2014, 61 percent were students, monks and nuns,
all of whom live in congregate settings.
PERSPECTIVE OF RNTCP AND
PRIVATE HEALTHCARE PROVIDERS
™ The RNTCP at the central and local level are cognisant
of the TB burden and challenges faced by Tibetan
refugees, and there is a strong commitment at the
RNTCP’s Central TB Division level to address these
issues. Under The Global Fund new funding model
(October 2015 to December 2017), Tibetan Voluntary
Health Association (TVHA) has been included as a
sub-recipient of the CTD, which is one of the principal
recipients of The Global Fund TB grant.
™ The Global Fund grant is expected to support
interventions aimed at increasing TB awareness, ACF
and contact tracing in congregate settings. It is also
expected to support capacity building in terms of health
workforce and infrastructure development.
™ RNTCP staff at the state and district levels shared some
challenges in collaboration with the Tibetan health
facilities: differences in the diagnostic algorithm and
treatment regimen followed by both entities, difficulty
in coordinating at the local level since decision making
is centralised at the DoH level, concerns about the
quality of sputum microscopy and DOT, and inadequate
sharing of data regarding TB and other diseases.
™ The assessment team’s expectation is that many of
these issues will be resolved once the new Global Fund
grant is in place and more training plans are organised
to train Tibetan health facilities to notify TB cases using
the RNTCP web portal, Nikshay. There will be more
alignment in practices once RNTCP rolls out plans to
switch to daily treatment throughout the country and
move towards individualised DST-guided treatment in
the coming years.
™ Related to private healthcare providers, the perception
is that only affluent Tibetans or those with serious
health problems go to private hospitals, often those
offering tertiary care services. Generally, Tibetan
patients prefer to avail themselves of services offered
by Tibetan health facilities, including Men-Tsee-Khang
centres for routine health problems, or to go to nearby
health facilities of the Indian government.
KEY FINDINGS FROM THE SURVEY OF
THE SEVEN TIBETAN HOSPITALS, 2011-2014
™ All seven hospitals returned the completed
questionnaire. The seven hospitals are Delek Hospital
at Dharamshala in Himachal Pradesh; Mundgod,
Kollegal, Hunsur and Bylakuppe in Karnataka;
Gajapati Hospital in Gajapati district (Odisha); and
Dekylling at Dehradun in Uttarakhand. Self-reporting
questionnaires were received from all hospitals.
™ A decline is observed in the number of presumptive TB

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patients tested by sputum microscopy as well as the
number of TB cases managed by the hospitals over the
three years 2012-2014.
™ In 2014, 347 TB patients were started on treatment,
including 270 new cases, 55 retreatment cases, 21
MDR-TB and one XDR-TB case.
™ Delek Hospital contributed towards 57 percent of TB
case management over four years 2011-2014, while
91 percent of TB cases are managed at four major
hospitals: Delek, Bylakuppe, Dekylling and Mundgod.
™ Around 83 percent of drug-sensitive TB cases (DS-TB)
are in the productive age group of 15-54 years, with the
remaining 9 percent among the age group 55 years and
over, and 6 percent among the age group 0-14 years.
™ Every year 30 to 35 percent of all DS-TB cases are
among females. The male-female discrepancy is less
or non-existent in 0-14 age group. On average, females
accounted for 33 percent of all cases over the four-year
period.
™ Treatment outcomes of patients registered for treatment
in the seven hospitals is impressive; over 90 percent for
new and retreatment cases in the past 2 years (2013-
2015). Outcomes of MDR-TB patients ranged from
82 percent among patients registered in 2010 to 59
percent in 2012. This is higher than the national and
global treatment outcome rates of MDR-TB patients.
The reason for the decline in the latest cohort needs
to be looked at; one possible reason being the small
number of patients (27 in the 2012 cohort), which can
easily fluctuate the percentage.
™ Review of CBNAAT (GeneXpert) services at
Mundgod, Bylakuppe and Delek hospitals suggest that
there is sub-optimal utilisation of CBNAAT services
at all three centres. On an average, only about one (at
Bylakuppe and Mundgod) and two to three (at Delek)
are processed per day. Error rates for sputum samples
are 3 to 17 percent. Error rates for extra-pulmonary
samples at Delek Hospital are in the range of 7.7 to
21.7 percent. All centres reported annual calibration
by LabIndia, within the one year preceding. Inventory
management is automated and centralised, and the
laboratories do not maintain stock registers.
™ Linkage with RNTCP: In general, TB patients are
diagnosed and managed by the DoH, though a minority
of health facilities may use RNTCP drugs or refer
them to the RNTCP for diagnosis and treatment. The
latter occurs when there is no DoH health facility in
the settlement. In addition, some facilities like Delek
Hospital maintain RNTCP registers (lab and treatment)
and regularly notify TB cases to the RNTCP though
Nikshay. The lab also participates in RNTCP’s EQA
system for sputum microscopy.
™ All seven hospitals, except Gajapati district (Odisha))
and Dekylling, are reported to be registered separately
as NGOs/Societies.
™ RNTCP-trained doctors, nurses and lab technicians are
available at Bylakuppe, Dekylling, Mundgod, Gajapati
district (Odisha), Kollegal and Delek. Hospitals in
Bylakuppe, Mundgod, Hunsur and Gajapati district
(Odisha) reported current vacancies in staff positions.
At Delek the chief medical officer is a TB specialist,
and another doctor is also trained in programmatic
management of drug-resistant TB (PMDT).
™ All hospitals reported that they receive budgets from
DoH for TB work. Delek Hospital receives independent
funding from other sources as well.
™ Dekylling, Delek, Hunsur and Kollegal reported
preparation of quarterly reports and doing occasional
data analysis.
KEY FINDINGS FROM THE SURVEY OF
OTHER TIBETAN HEALTH FACILITIES 2011-2014
™ There are six Tibetan Primary Health Centres (TPHCs)
under the Department of Health in India. These
are located at Bir in Himachal Pradesh, Ladakh in
Jammu and Kashmir, Mainpat in Chhattisgarh, Miao
in Arunachal Pradesh, Majnu Ka Tila (common name
for Samyeling) in Delhi and Bhandara in Maharashtra.
Information was received from all TPHCs except
Bhandara.
™ AllfivereportingTPHCshavebinocularorfluorescence
microscope but the utilisation of sputum microscopy is
minimal except at Bir TPHC.
™ Intheperiod2011-2014,fourofthesixTPHCsmanaged
a total of 123 TB patients: 23 patients, including 1 DR-
TB patient, in Bir TPHC; 33 patients in Ladakh TPHC;
20 patients, including 2 DR-TB, in Mainpat TPHC; 47
patients, including 12 DR-TB, in Delhi TPHC.
™ Treatment outcomes of drug-sensitive TB cases
reported by three THPCs (Bir, Mainpat and Delhi)
showed an 82 percent treatment success rate, with the
remaining 18 percent reported as transferred-out cases.
™ In addition to the TPHCs, there are 20 Tibetan health
clinics in India, which are also part of the DoH network.
The clinics at Kamrao and Dolanji are managed by one
nurse each, and the clinic at Sataun is managed by a
community health worker who is trained in TB. There
is no infrastructure for TB diagnostics. There was no
data on TB treatment services.
Executive Summary

12
™ Two school health facilities completed the
questionnaire: Tibetan Homes Foundation (THF) in
Mussoorie, Uttarakhand, and Upper Dharamshala
Tibetan Children’s Village (TCV). Both centres have
a regular doctor and in-patient facilities. Both also
have binocular microscopes and X-ray facilities. In
the period 2011-2014, THF reported 39 new cases,
five retreatment cases, and two MDR cases; TCV-UD
reported 57 new cases and two MDR cases during the
same period
COMMUNITY PERSPECTIVES
Knowledge of symptoms of TB is very high among all
groups interviewed—TB patients, monks and nuns, home
mothers, youth living in youth hostels, schoolchildren and
community leaders . They are aware of cough etiquette and
the need for adhering to TB treatment. The main sources
of knowledge of TB are the doctors and the nurses in
DoH facilities. For schoolchildren, nurses at the school
clinics are the first point of contact and source of health
information.
Almost all Tibetan community members reported that
they prefer to get treatment for TB from Tibetan DoH
facilities, since they can communicate with staff in their
own language, the facilities have a more patient-friendly
environment, and treatment costs less, as they can avail
themselves of benefits for Tibetan patients.
Mass media does not seem to be an effective tool to reach
out to this community except for posters (in English and
Tibetan) that are displayed in places frequented by them.
Tibetans live in a closed community; therefore peer-to-peer
communication may be the most effective communication
channel. Community members were aware of the
importance of a balanced diet and the need for nutritious
food, particularly during illnesses. Some respondents were
concerned with misuse of tobacco and alcohol among the
young population in their community.
KEY RECOMMENDATIONS
While the following key recommendations are specific
to the TB programme, their implementation should be
planned in the context of the overall health system and
findings of other assessments, in order to seek synergies
and efficiencies where possible.
1. Maintain TB control as a priority
Maintain the priority of the TB control programme given
the disproportionate burden of TB among Tibetan refugees
in India. Develop a costed strategic plan for TB as well as
technical and operational guidelines that take into account,
among other things, the existing healthcare services for
Tibetan refugees, standards for TB diagnosis and treatment,
and recording and reporting systems that are suitable
for this population and setting. The technical guidelines
should encompass all aspects of TB care and prevention,
including airborne infection control, preventive therapy,
management of childhood extra-pulmonary TB, and co-
morbidities such as diabetes mellitus and HIV infection.
Specifically, allocate resources and mobilise additional
external resources to secure adequate funding to provide
TB care and prevention services.
2. Establish coordination between central
and local departments
Establish an interdepartmental coordination committee
with representatives from other sectors offering health
services, such as the Departments of Religion and
Education and the Tibetan traditional system of medicine
at the central and local levels. The local level committee
could include representatives of the DoH’s local health
facilities, and representatives of schools, monasteries and
settlements.
3. Strengthen the structure and capacity
of the TB programme
Strengthen the central TB programme management unit
with enough human resources and capacity to develop
plans and guidelines to coordinate, implement, supervise
and monitor the TB control programme. Develop and
train staff to follow uniform diagnostic and treatment
algorithms for both drug-sensitive and drug-resistant TB,
for both routine/passive and active case-finding across
the entire DoH network. In addition, standard checklists
and SOPs are needed for supervision and monitoring,
contact tracing, laboratory procedures, etc. Ensure key
positions are filled with trained staff in all hospitals and
primary health centres. This may require appointment
of additional staff and task shifting, as several facilities
were found to be under-staffed. Develop and implement
a training plan for different cadres of staff based on their
roles and responsibilities. Consider a formal tie-up with
RNTCP training institutes such as the National Institute
of Tuberculosis and Respiratory Diseases in Delhi, the
National Tuberculosis Institute in Bengaluru or offices
of the RNTCP State TB Officers for ongoing training of
Tibetan DoH staff.
4. Develop standardised SOPs and guidelines
Detailed assessment by subject-matter experts on some
aspects of the TB programme is required to come up
with recommendations or SOPs/guidelines. This includes

13
airborne infection control measures both at health facilities
and congregate settings in the community (monasteries,
school hostels, etc.), as well as the laboratory services
and network, the recording and reporting system, human
resource planning and capacity building for the TB
programme, and other specialised technical areas.
Standardise the forms, registers and reports used at all
health facilities and ensure submission of reports by all
reporting units to a central unit to have a better estimate of
the TB burden, to monitor programme performance, and to
provide supportive supervision where needed. This could
be done as part of the overall health information system
for the DoH, the Epi Info–based data entry system that has
been recently introduced, or a new case-based electronic
reporting system similar to RNTCP’s Nikshay web portal.
5. Decentralise for early diagnosis and easier access
Decentralisation of diagnostic services is needed, as
the majority of cases are being diagnosed at only a few
hospitals. Where health facilities do not offer TB services,
build formal referral systems (patients or specimen
transport) to a nearby facility within the Tibetan DoH or
the RNTCP network. Sputum collection and transportation
by a trained community volunteer could be tried out in
settlements which do not have health facilities. Similarly,
DOT should be further decentralised by establishing more
DOTcentres in schools, traditionalTibetan Medical System
(TMS) health facilities, monasteries, nunneries and within
settlements. A community DOT provider network could
be developed by training former TB patients and other
community volunteers.
6. Establish linkages with India’s Revised
National TB Control Programme
While there are examples of good collaboration
between Tibetan DoH and RNTCP, this could be further
strengthened, particularly at the level of the local staff of
RNTCP and DoH facilities. The RNTCP network could
provide referral services for advanced laboratory services,
management of DR-TB and TB-HIV co-infection in
locations where DoH facilities do not offer these, include
DoH TB labs in the RNTCP EQA network, and supply
free drugs once daily regimens are rolled out. Tibetan
DoH facilities offering TB services should submit reports
regularly to the RNTCP locally and through the Nikshay
portal once they are trained to do so.
Executive Summary

15
15
BACKGROUND
these congregate settings, among them majority are youth.
Migration: It is also estimated that 75 percent of the
in-exile population has migrated since 1998. About 52
percent of these migrants have changed their residences
permanently for education and economic opportunities.
Future trends indicate migration of 68 percent of the
population to other foreign countries, mostly Europe and
United States.
Household size: The average household size of Tibetan
refugees in India is 3.8, with larger household sizes in the
LadakhregionofJammuandKashmir(5.2)andDhondeling
in Karnataka (5), whereas it is 2.4 in Dharamshala.
1.1 DEMOGRAPHIC PROFILE OF THE
TIBETAN SETTLEMENTS IN INDIA
The total population of the Tibetan diaspora in exile is
127,935, of which 94,203 live in India, 13,514 in Nepal,
1,298 in Bhutan and 18,920 in the rest of the world.1
Tibetans in exile make up about 3 percent of the total ethnic
Tibetan population in the world. The Tibetan refugees in
India reside in 39 settlements and sub-settlements spread
across several states in the country. The largest of these
settlements (Fig. 1.1) include:
™ Dekyilling – 5,686
™ Dharamshala – 13,701
™ Doeguling (Mundgod) – 9,847
™ Ladakh – 6,769
™ Lugsam (Bylakuppe) – 9,229
Almost 48 percent of the refugee population resides in
these five settlements.
Demographic profile: In the Indian sub–continent (India,
Nepal, Bhutan), out of the total 109,015 Tibetan refugees,
60,599 are male and 48,416 female. Out of these over 70
percent (42,633) of the males and 67 percent (32,398) of
the females are in the economically productive age group
of 15-64 years. In India, there are 24,183 workers, 4,515
marginal workers and 31,517 non-workers.2
Congregatesettings:ThecongregatesettingsintheTibetan
settlements include residential schools, monasteries,
nunneries and youth hostels. There are 60 monasteries and
nunneries, 63 schools, which comprise both day schools
and residential schools, and four youth hostels in India. Of
the 94,203 Tibetan refugees living in India, it is estimated
that nearly 50,433 (53.5%) of the Tibetan population live in
1.
Planning Commission Central Tibetan Administration (2009). Demographic Survey of Tibetans in exile-2009. (TDS 09)
2.
Note: According to the TDS 2009, any individual who has engaged in economically gainful activities for a period of 183 days or more is a worker. If
an individual works for less than that period, he or she is considered a marginal worker.
Fig. 1.1. Tibetan settlements in India
Ref. 4. Map Source: The Tibet Fund. http://www.tibetfund.org/
prog.html. Accessed on 26.08.2015
1
1.2 OVERVIEW OF THE CENTRAL TIBETAN
ADMINISTRATION AND THE TIBETAN HEALTH SYSTEM
The Central TibetanAdministration (CTA) was established
by His Holiness The Dalai Lama in 1959 shortly after his

16
exile from Tibet. The CTA is headquartered in McLeod
Ganj, Dharamshala, India. In addition to political
advocacy, it administers a network of health facilities,
schools, monasteries and nunneries, as well as settlements
through its various departments.
There are seven departments within the CTA: the
Department of Religion and Culture, the Department of
Home, the Department of Finance, the Department of
Education, the Department of Security, the Department
of Information and International Relations and the
Department of Health (Fig. 1.2).
of Home are local administrators. The department is also
responsible for the transfer of its staff.
The department with financial assistance from its donors
bears running expenses of these hospitals and PHCs,
including salaries of the staffs and other recurring and
non-recurring expenses. On top of that, the department
also undertakes the implementation of special projects in
the interest of primary healthcare services.
The Health Kalon and the Health Secretary on an ex-
officio basis are the Chairman and Vice-Chairman of the
Board of Directors (BoD) of both the Tibetan Medical
and Astrological Institute (TMAI) and the Tibetan Delek
Hospital, located in Dharamshala, Himachal Pradesh. All
the bills passed in the meeting of BoD are thoroughly
discussed and approved under the Chairmanship of the
Health Kalon and the Health Secretary.
Implementation, monitoring and evaluation
of health programmes
Prioritizing the importance of community participation in
all the healthcare programmes or projects, the DoH has
formulated health committees in each settlement to carry
out and assess healthcare activities in their respective
settlements. The committee meets at least thrice a year
to discuss various possibilities for improving community
healthcare services. The committee comprises settlement
officers who are the chairperson on an ex-officio basis and
the executive secretaries or local health workers. In addition,
local group leaders are the members of the committee who
are responsible for implementing and reporting on every
healthcare event carried out by the DoH at that settlement.
The DoH monitors and evaluates the healthcare services
through feedback and updates from local health centres in
the form of periodic reports as well as during field visits.
Programmes under the Department of Health
The DoH runs several programmes, such as the Health
Data and Research Program, the Disease Control Program,
the Emergency Medical Program, Health Education, the
Mother and Child Health Program, the Telemedicine
Project, the Tibetan Torture Survivors Program, the
Tibetan Medicare System, Water and Sanitation, and the
Welfare Program.
Under the Disease Control Programs, the key sub-
programmes are the TB Control Program, the Leprosy
Control Program and the HIV/AIDS Control and
Prevention Program
The Health Education desk of the department strives to
increase awareness of preventive measures concerning
Fig. 1.2: Organisational structure of the Central Tibetan
Administration
The Tibetan health system
Recognising the importance of good health of the Tibetan
refugee community, the Central Tibetan Administration
(CTA) established the Department of Health (DoH)
in December 1981 to provide curative and preventive
healthcare services by managing and financing healthcare
centres, as well as by planning a comprehensive healthcare
system for the Tibetan refugees in India, Nepal and
Bhutan. The department is registered in the name of the
Tibetan Voluntary Health Association (TVHA) under the
Indian Society Registration Act XXI 1860. The main aim
of the department is to make Tibetan refugee settlements
viable by improving the basic health status of Tibetans
in exile. It includes providing adequate, equitable and
holistic primary healthcare services to all Tibetan refugees
through its primary health centres (PHC) and creating
and expanding the public healthcare programme in the
community for disease prevention by promoting healthier
lifestyles and a cleaner environment. With its primary goal
embodied in the motto “Health for All,” the department
extends its healthcare services to both Tibetans and local
Indian residents.
The staff is appointed and administered directly by
the DoH. The department has also appointed several
executive secretaries to administer hospitals and PHCs.
The respective settlement officers under the Department

17
mother and child healthcare, and against various diseases,
including waterborne diseases, TB, sexually transmitted
infections, HIV/AIDS and substance abuse. The desk
has produced numerous booklets, pamphlets, posters,
charts, and even audio-visual kits like CDs and DVDs. All
these materials are produced in both English and Tibetan
versions and freely distributed among the general public.
The Tibetan Medicare System is built on public-private
partnership model and creates a health fund across the
entire Tibetan exile community. It providesequitable and
comprehensive healthcare coverage on a yearly basis
designed to serve the healthcare needs of the entire Tibetan
exile community by creating a more sustainable financing
source.
Under the Health Data and Research Programme,
the department plans to install a computerised health
information system (HIS) in all health centres. After the
successful installation of the software, comprehensive HIS
data will be available for routine monitoring and analysis.
The Mother and Child Health Programme includes
immunisation, perinatal care, mother and child’s nutrition,
prevention and treatment of childhood infectious diseases
and control of sexually transmitted infections and
reproductive tract infections.
The Welfare Program includes care for the disabled and
the destitute and the Mental Health Program. The DoH has
recently introduced the Community Based Rehabilitation
Program in the settlements to give extra care to disabled
people and to make them self-reliant through rehabilitation.
A special project desk of the DoH ensures the provision of
safe drinking water, construction of public and individual
toilets, provision of equipment at the health centres,
construction of health centres, repair and maintenance
of the health centres and provision of ambulances to the
hospitals, and so forth.
The healthcare needs of the Tibetan refugees in India is
met through a network of seven hospitals, six primary
health centres and 26 17 health clinics spread across India.
All these health facilities form independent reporting units,
reporting directly to the DoH. In addition, there are other
autonomous health institutions and health facilities run
by other departments of the CTA in schools, monasteries
and nunneries. Annexures 3 and 4 contain the list of health
facilities.
Hospitals: Each hospital provides health services to
a population of 5,000-16,000. These institutions are
equipped with all basic TB diagnostic and treatment
facilities, including TB wards and TB isolation units for
male and female patients.
The hospitals consist of two divisions—administrative and
medical—and are administrated through an autonomous
board of management. The daily management of each
hospital is supervised by the hospital administrator while
the chief medical officer heads the medical division.
Besides general health services, these institutions also
provide services for mothers and children, reproductive
health, HIV, mental health, and tuberculosis, among others.
Tibetan primary health centres (TPHC): The DoH also
runs a network of six primary health centres (PHC), to
serve settlements with populations ranging from 1,000–
7,500. These health facilities are fully equipped with basic
medical equipment and treatment facilities and are staffed
with either resident or visiting doctors, staff nurses and
community health workers. These institutions provide
preventive, promotive and curative services to the Tibetan
population of the settlement. The daily administration
of these health facilities is supervised by the respective
settlement officer. The PHCs are located in Choepheling,
Miao inArunachal Pradesh; Bir Dege in Himachal Pradesh;
Sonamling, Ladakh in Jammu and Kashmir; Samyeling
(commonly known as Majnu ka Tila), Delhi; Phendeling,
Mainpat in Chhattisgarh; and Norgeyling, Bhandara in
Maharashtra
Health clinics: These health facilities cater to small
populations and are staffed with community health
workers with a doctor visiting once every week or two
weeks. The clinics are equipped with all basic equipment
Fig. 1.3: Organisational structure of the Department of
Health, Central Tibetan Administration, Dharamshala
Background

18
and treatment facilities, and provide OPD services for
health programmes such as MCH, RH, and DOTS. There
are 17 Health Clinics in India and these are administrated
by their respective settlement officer.
Autonomous institutions: The Delek Hospital and the
Tibetan Medical and Astrological Institute, both located
in Dharamshala are the main autonomous health centres
under the CTA. The Delek Hospital, although distinctly
autonomous, falls under the purview of the DoH. The
hospital has an in-patient capacity of 45 beds, the majority
of which are occupied by TB patients. Delek has played a
very important role in the prevention and treatment of TB
among Tibetans. Besides TB, Delek Hospital also provides
treatment to Tibetans as well as local Indians for all major
infectious and non-infectious diseases.
The Tibetan Medical andAstrological Institute (Men-Tsee-
Khang) aims to preserve, promote and practice the Tibetan
system of astronomy, astrology and medicine. Under this
system, patients are treated holistically, with treatments
customised for individual needs. The institution has 54
branches across India, out of which 36 are in Tibetan
settlements and 18 in cities and rural areas.
Health facilities under other departments
The CTA also has health facilities under the Department
of Religion for catering to the monasteries and nunneries
and under the Department of Education for catering to
the schoolchildren and staff. These health facilities are
independently staffed, and there is no formalised referral
and reporting system among these health facilities and the
DoH.
The Department of Education has 66 schools under four
administrative structures in India, namely the Tibetan
Children’s Villages (TCV), the Central School for Tibetans
(CST), Sambhota Tibetan School (STS) and the Tibetan
Homes Foundation (THF). Besides these health facilities,
the Tibetan population also accesses the services of the
Revised National TB Control Programme, local private-
sector allopathic doctors, local Ayurveda services and
practitioners of the Traditional Tibetan Medicine system.
1.3 BURDEN OF TB AMONG TIBETANS IN EXILE IN INDIA
Tuberculosis (TB) continues to be one of the biggest
public health challenges among Tibetan refugees and the
leading cause of death due to infectious disease. It has been
documented that nearly 30 percent of all Tibetan refugees
living in India have been infected with TB. Severe physical
hardships of escaping across international borders, living
in poverty in unhygienic and overcrowded temporary
conditions, hunger, stress and mental anguish have led
to further aggravation of TB incidence among them,
increasing the transmission of TB to a new population
pool. Nearly 53.5 percent of Tibetan refugees in India live
in congregate settings such as monasteries, nunneries and
boarding schools, which are likely to facilitate ongoing
transmission in the community.
TB incidence among Tibetan refugees is substantially
higher than in the local native host population. In the period
1994-1996, the Tibetan Voluntary Health Association
(TVHA) reported an extremely high average annual TB
incidence of 835/100,000, while in 2010 it was reported
as 431/100,000 in the Tibetan populations. In 2008,
the incidence rate among Tibetan refugees in Himachal
Pradesh was estimated to be 816/100,000 (extrapolated
from a population of 22,000). This was significantly higher
than the incidence rate of 168/100,000 among native Indian
population in the same year. Similarly, the incidence rates
were substantially high in the larger Tibetan settlements
in South India. In Bylakuppe it was 856/100,000, while in
Mundgod it was 772/ 100,000.
The incidence of multidrug-resistant TB (MDR-TB) has
also been very high in this group of people. In 2010, the
incidence of MDR-TB among the Tibetan population in
India was reported as 69/100,000 according to a field
survey jointly conducted by TVHA and Delek Hospital.
About 14.5 percent of new TB cases had MDR-TB and
32.4 percent of the retreatment TB cases had MDR-TB.
Also 6 percent of all cases had MDR-TB, though only 10
percent of the patient specimens were submitted for culture
and drug-susceptibility testing. The rate of HIV infection
among TB cases is less than 1 percent.
This assessment aimed at assessing the existing health
system, its strengths, weaknesses and challenges. It
also sought to assess the possible ecosystem of health
services available to this population and the health-
seeking behaviour of the patients and communities in the
settlements. Another aim was to provide cost-effective and
sustainable recommendations to decrease the large pool of
latent infections, the high incidence of TB disease and the
emergence of drug-resistant TB (DR-TB) among Tibetan
refugees.

19
19
largest settlements and one medium-sized settlement were
selected. To provide greater geographical variation, two
states, namely Himachal Pradesh and Uttarakhand, were
chosen from North India and one state, Karnataka, was
selected from South India (Fig. 2.1).
GOAL
To assess the tuberculosis (TB) care and management
services in Tibetan settlements in India to ensure early
diagnosis and complete treatment of TB among Tibetan
refugees in India.
OBJECTIVES
1. To assessment the existing health system, practices,
barriers and gaps in Tibetan settlements in the context
of TB patient care and management services.
2. To assess the current system of referral, recording and
reporting between health facilities under the Tibetan
Department of Health and the local private sector,
the Tibetan traditional system of medicine and the
Government of India’s Revised National TB Control
Programme (RNTCP).
3. To assess the current system of referral, recording and
reporting between the health facilities reporting to
Department of Health and health facilities reporting to
other departments such as Department of Religion and
Department of Education.
4. To explore the health-seeking behaviour of Tibetan
refugee patients and of the communities in the Tibetan
settlements.
METHODOLOGY
Assessment Design
This assessment employed mixed methods, using both
quantitative and qualitative techniques to collect data from
the field. Through this assessment, the team intended to
capture data under the following broad heads:
1. Governance and programme management
2. Service delivery
3. Community perspectives
Assessment Sites
Out of all the Tibetan settlements in India, four of the
Fig. 2.1. Assessment sites selected among Tibetan settlements
of India.
In Himachal Pradesh, one large settlement, namely
Dharamshala, and one medium settlement, namely Bir,
were selected. In Uttarakhand, Dehradun, which is a
large settlement, was selected and in Karnataka, two
large settlements, namely Bylakuppe and Mundgod, were
chosen for the assessment.
METHODS AND MATERIALS
2

20
In each settlement, health facilities under the Department
of Health (DoH), Department of Education (DoE) and
Department of Religion (DoR) were selected.Additionally,
monasteries and nunneries and schools were also identified.
The local RNTCP unit was included in the assessment. A
local private-sector practitioner and a Tibetan traditional
practitioner in each location were also included for the
assessment.
The youth hostels of the Tibetan refugees are located in
three places, namely Delhi, Bengaluru and Sarnath. For
the purpose of this assessment, youth hostels in two cities,
Delhi in North India and Bengaluru in South India, were
selected.
Assessment Population
The following population were involved in the assessment:
Governance and programme management
™ Central Tibetan Administration: Health Minister,
Secretary of Health, Deputy Secretary, Head of Public
Heath, Programme Manager (TB), key personnel from
the Department of Education, Department of Religion
and Department of Home and the Settlement Officers/
Health Executives.
™ RNTCP: Additional Deputy Director General TB,
and State TB Of icers
Service delivery
™ Tibetan settlements: Health practitioners of health
facilities under the DoH, DoE, DoR, private sector,
traditional medicine; laboratory technicians of health
facilities under the DoH, DoR, DoE; staff nurses of
health facilities under the DoH, DoR, DoE; community
health workers under the DoH, DoR, DoE; chemists
(pharmacists) in the private sector; assistant health
practitioners of traditional medicine
™ Local RNTCP: District TB Officer of local unit;
Supervisor of local unit
Community perspectives
™ Patients; home mothers in schools; youth in youth
hostels; monks; nuns; schoolchildren; families residing
in Tibetan settlements; community leaders
Sample Size
High-Level Personnel for In-Depth Interviews Number
Health Ministry
The Health Minister 1
Secretary of Health 1
Joint Secretary of Health 1
Department of Health
Public Health Officer and Head DoH 1
Programme Manager (TB) 1
Administrative Head of Delek Hospital 1
Settlement Officers/Health Executives 5
Allied Departments
Key personnel from the Department of Education 1
Key personnel from the Department of Religion 1
Key personnel from the Department of Home 1
Revised National TB Control Programme
Additional Deputy Director General TB 1
State TB Officers 3
Total 18
Service delivery
Central Tibetan Administration: Department of Health
Health Personnel Dharamshala Bir Dehradun Bylakuppe Mundgod Total
Doctor 1 1 1 1 1 5
Laboratory Technician 1 1 1 1 1 5
Staff Nurse 1 1 1 1 1 5
Community Health Worker 1 1 1 1 1 5
Total (DoH) 4 4 4 4 4 20
Central Tibetan Administration: Department of Education
Doctor 1 1 1 1 1 5

21
Total (DoE) 4 4 4 4 4 20
Central Tibetan Administration: Department of Religion
Doctor 1 1 1 1 1 5
Total (DoR) 4 4 4 4 4 20
Private-Sector Practitioners
Doctor 1 1 1 1 1 5
Chemist 1 1 1 1 1 5
Total (PS) 2 2 2 2 2 10
Tibetan Traditional Medicine Practitioners
Health Practitioner 1 1 1 1 1 5
Assistant Health Practitioner 1 1 1 1 1 5
Total (TMS) 2 2 2 2 2 10
Revised National TB Control Programme
DTO 1 0 1 1 1 4
Supervisor 1 1 1 1 1 5
Total (RNTCP) 2 1 2 2 2 9
Key Informant Interview
Key Informant Dharamshala Bir Dehradun Bylakuppe Mundgod Delhi Bengaluru Total
Patients 2 2 2 2 2 10
Home Mothers (Schools) 2 2 2 2 2 NA NA 10
Youth in Youth Hostel NA NA NA NA NA 5 5 10
Total () 4 4 4 4 4 5 5 30
Focus Group Discussions
Discussion Participants Dharamshala Bir Dehradun Bylakuppe Mundgod Total
Monks 1 1 1 1 1 5
Nuns 1 1 1 1 1 5
School Children (Boys) 14 and above 1 1 1 1 1 5
Methods and Materials

22
School Children (Girls) 14 and above 1 1 1 1 1 5
Community leaders/block leaders 1 1 1 1 1 5
Community members 1 1 1 1 1 5
Total (FGD) 6 6 6 6 6 30
Summary of Sample Size
Key Informant Number
Governance and Programme Management 18
Service Delivery 89
Community Perspectives 30
Total KII 137
Focus Group Discussion Participants 30
ASSESSMENT METHOD
Quantitative method
Quantitative desk reviews and responses from interviews
were collected to document the perspectives at three levels:
™ Governance and programme management
™ Service delivery
™ Community perspectives
Desk review of existing policy documents and guidelines
related to management of health systems under the various
departments under the CTA, namely the DoH, DoR and the
DoE, was done. These documents were sought from the
CTA and the DoH by the Union assessment team and via
their websites using suitable search engines.
Desk review of existing policy guidelines of the Central TB
Division of the Government of India’s Ministry of Health
for special provisions to vulnerable communities including
Tibetan refugees was also carried out. These documents
are available at the official website of Central TB Division.
Service delivery
Desk review was conducted using aggregate routine data
of the Tibetan TB programme, which is routinely collected
and collated by the DoH, from the period 2012–2014, or
later as available. The DoH shared the relevant aggregated
data on theTB programme with the Union team for analysis;
this collated data did not include patient particulars, so as
to maintain patient confidentiality.
Additional information regarding existing health
infrastructure, resources and service delivery were
collected through self-reporting questionnaires. These
self-administered questionnaires were developed by
the Union team in concurrence with the DoH. The self-
administered questionnaires were dispatched by the
DoH via email and post. The information via the self-
administered questionnaires were collected, cleaned and
collated by the DoH. Patient particulars were not included
in the self-administered questionnaires, to maintain patient
confidentiality. Final aggregate data of all functional health
facilities were shared with the Union team for analysis.
A facility survey for each health facility in the selected
assessment settlements was included in the assessment. This
was conducted during the on-site visit by the Union team.
With this, the Union team sought to triangulate the existing
reports with the records to understand the quality of the
recording and reporting system and any challenges therein.
This facility assessment also consisted of questionnaires
on existing health infrastructure, staffing, training and
equipment, which complement the findings of the self-
administered questionnaire, to bring greater perspective
to the assessment. This checklist was administered by the
Union team during their on-site visit to each settlement.
Qualitative method
Qualitative tools were administered to document the
perspectives of assessment participants at three levels:
™ Governance and programme management
™ Service delivery
™ Community perspectives
Under this section, policy perspectives were documented
from in-depth interviews with key high-level personnel
in the DoH and allied departments such as the DoR, DoE
and Department of Home under the CTA. This section
also included the perspectives of the settlement officers or
health executives of each settlement.

23
To document existing high-level policy perspectives
regarding existing services, challenges and opportunities,
in-depth interviews were conducted with key personnel at
the Central TB Division, Government of India.
This section provided information on governance and
programme management perspectives to contribute to
Objectives 1, 2 and 3 of this assessment.
Informed written consent was taken before the start of
the interview. The interviewer, who was part of the Union
team, noted the responses on moderator sheets. No audio
recordings were made of the interviews.
Assessment instrument. A semi-structured questionnaire
was administered to CTA personnel of the DoH and allied
departments by a member of the Union assessment team
during the field visit to Dharamshala only, while the
questionnaire for RNTCP personnel was administered
by the Union team in Delhi. The semi-structured
questionnaires for the settlement officers/health executives
were administered by the Union team in their respective
settlements.
Service delivery
Through this section, the perspectives of health personnel
at the service delivery level was captured, including
knowledgeandpractiserelatedtoTBcareandmanagement,
challenges in service delivery, and opportunities for
improvement.
It included in-depth interviews with doctors, staff nurses,
community health workers and other paramedical staff
such as laboratory technicians and pharmacists of health
facilities reporting to the DoH, CTA.
Under this section, the assessment also documented the
healthcare delivery perspectives of health personnel
working in health facilities reporting to allied departments
such as the DoR and DoE, CTA.
To document existing referral, recording and reporting
and service delivery linkages with other existing health
systems, in-depth interviews were conducted with District
TB Officers, local supervisors and other paramedical staff
of local Government of India RNTCP units.
In-depth interviews were also conducted with doctors
working in the private sector and practitioners of the
Tibetan traditional system of medicine.
Informed written consent was taken before the start of the
interview. The responses were noted by the interviewer,
who was a part of the Union team in moderator sheets. No
audio recordings were made of the interviews.
Assessment instrument. A semi-structured questionnaire
was administered by the Union team during the field visits
to the settlements.
The responses collected by the assessment team through
the various in-depth interviews and the focus group
discussions during the course of the assessment field visit
were coded. A qualitative measure of the responses, such
as content analysis, was applied after data coding and
cleaning by the Union assessment team.
The assessment endeavoured to document the perspective
of patients, members of families living in the Tibetan
settlements with a special focus on women and migrants,
and community leaders regarding TB, including their
conception of modes of transmission and prevention and
their behaviours pertaining to seeking treatment.
A scoping exercise and analysis of existing routine data for
this assessment indicated that among the Tibetan refugees,
the people most vulnerable to TB are students and monks
and nuns living in congregate settings, which is consistent
with reviewed literature. Hence this assessment specifically
aimed at documenting the drivers of TB in these schools,
among schoolchildren and their caregivers, namely home
mothers, and also in monasteries and nunneries among
monks and nuns. A similar endeavour was done in youth
hostels as these are also congregate settings.
Interviews with patients, home mothers and youth living
in youth hostels were conducted by the Union assessment
team during the field visit. Semi-structured questionnaires
were used to document their perspectives. Informed
written consent was taken from each participant before the
start of the interview. No audio recordings were made of
the interviews.
Focus group discussions were conducted with those most
vulnerable to TB, namely the schoolchildren, monks and
nuns. Focus group discussions were also conducted for
families living in Tibetan settlements and community
leaders.
The focus group discussions were conducted with semi-
structured focus group discussion guides after taking
informed written consent from the participants. Individual
signatures of all participants of each focus group discussion
were taken on one consent form.
All the responses were noted by the moderator of the focus
group discussion on moderator sheets. No audio recordings
were made of the proceedings. The participants included
in the focus group discussions were different from those
interviewed for the key informant interviews, as the target

24
groups were different.
The responses of the Congregate Residents interviews
and the focus group discussions met the requirements of
Objective 4 of this assessment.
DATA MANAGEMENT
Data collection
All assessment operations such as data collection, data
entry, data analysis and report writing were managed by
the Union team.
Desk review for quantitative assessment
For the desk review, aggregate routine report data were
given by the DoH to the Union assessment team after
removing personal identifiers. This included the data of
seven major Tibetan hospitals.
The on-site facility data was collected by the Union
assessment team during their site visits to the settlements.
The data were collected in aggregate form and excluded
patient identifiers.
For the self-administered section of the assessment, the
tools developed by the Union assessment team were given
to all health facilities by the DoH. The DoH gave the data
to the Union assessment team once they received them.
Qualitative assessment questionnaires
and focus group discussion guides
Considering the key objectives, semi-structured
questionnaires with a special provision for recording
open-ended responses wherever required, were used. The
questionnaires and focus group discussion guides were in
English.
In-depth interviews
In-depth interviews were conducted with various
stakeholders, community representatives and patients
with tuberculosis who were willing to participate. It was
conducted by the co-investigators, who were well-trained
in qualitative research (MD in Community Medicine
and Master in Public Health) having more than 10
years of public health practice and research experience.
The investigator was well versed in Hindi, which was
well understood by the local inhabitants. The in-depth
interviews were conducted at a time and place convenient
to the participants using an interview guide. Each interview
took around 20 minutes. Participants were informed of the
purpose of the assessment. The investigator held one-to-
one interviews after obtaining permission and consent
to participate in the assessment. Only the participant
and the researcher were present during the interview. An
interview guide with broad open-ended questions was
prepared (attached as Annexures). After the interview was
over, the summary of the interviews was read back to the
participants to ensure participant validation. Field notes (if
any) from observations during data collection were made.
Focus group discussions
Focus group discussions consisting of 8-12 participants
who were willing to participate were undertaken in the
assessment area. Consent was taken from the group . It was
moderated by trained co-investigators (MD in Community
Medicine) with more than 10 years of public health and
research experience. Both the moderators were well versed
in the local language, Hindi. Focus group discussions
were conducted at the time and place convenient to the
participants. Moderators used semi-structured guidelines.
Discussions were noted down; no audio recordings were
made. The notes were transcribed verbatim on the day of
the focus group discussion. Efforts were made to create a
healthy environment for discussion.
Data confidentiality
To avoid risks associated with the disclosure of sensitive
information, although the names of the participants were
collected on the consent form, they were not present
in any of the other documents, such as the participant
information list. These documents had only the unique
codes as assessment ID. All completed questionnaires
and interview notes, and other assessment results are kept
locked in a dedicated storage facility, and access is limited
to the Union assessment team only.
Access files containing participant data is password
protected, and all personal identifiers (except assessment
ID) are removed from analytic files. Only Union staff have
access to the final data set. Names of participants will not
appear in any publication or reports. These reports and
publications consist only of aggregated analysed data.
The research team is responsible for data storage after the
completion of the assessment.
DATA ANALYSIS PLAN
Quantitative data analysis
Data were summarised using means or proportions
depending on the type of variable.
Qualitative data analysis
The assessment co-investigators noted down the
proceedings of the interviews and focus group discussions
and transcribed the responses on the same day. The
transcripts were analysed manually by two of the co-
investigators. Any difference was resolved by another
assessment investigator. The decision on coding rules and

25
theme generation was done using standard procedures and
in consensus. Similar codes were combined into themes.
The themes were described along with verbatim quotes.
The findings were reported using ‘Consolidated Criteria
for Reporting Qualitative Research’.
INFORMED WRITTEN CONSENT
All respondents in the assessment were given a brief
overview of the assessment and administered an informed
written consent at the start of the interviewing process. The
interviewer, who is a part of the Union assessment team,
read aloud the consent form to the person in the language
which the person understands. If the individual consented
to be a part of the assessment after having understood all the
relevant points, the interviewer requested the individual to
sign the consent form. If the participants of the assessment
were minors, i.e., below the age of 18 years, informed
written consent was taken from both the minor participant
and his or her legal guardian (parent or legal caregiver).
Since the children in residential schools stay separate and
far away from their legal guardians, the consent was taken
from a member of the school authority such as the home
mothers/school matrons.

26
26
it receives on health sector. The health budget comes under
specific heads, such as Maternal and Child Health, TB, etc.
They spend the health budget on hospitals, drugs, doctors’
fees, food, and conducting awareness camps, meetings, talks,
etc. They carry out regular health awareness camps/drives
and also participate in such events organised by the hospitals.
All TB drugs are provided free of cost to patients. For
diagnosis, a courier service is employed to transport the
sputum specimen to the hospital for testing. However,
despite all these measures, one of the officers was
concerned about the rising incidence of drug resistance
among TB patients in the settlements, especially in the
sweater seller group who start treatment but discontinue
due to side effects or resolution of symptoms.
It was learnt that the health facilities in the DoH, schools
and monasteries/nunneries do not report to their settlement
office; rather they report to their respective departments
(DoE, DoR), without any convergence at any level. Thus
there is no system of data consolidation, analysis and
feedback at the settlement office.
One of the officers expressed the need for more awareness
drives, especially in schools and colleges, and more
workshops. They also raised issues regarding erratic supply
of electricity. They also said that although there is no formal
engagement policy, they have good working relations with
the RNTCP, traditional medicine practitioners and private-
sector practitioners. They get an uninterrupted supply of
drugs, both first-line and second-line, from the RNTCP.
All TB patients are referred to the RNTCP for initiation
of treatment, but there is no mechanism for recording or
reporting of referred cases.
Interviews with personnel from the Department of Health
and with the TB programme manager
We conducted in-depth interviews with the head of
the Department of Health and with the TB programme
3.1 TUBERCULOSIS PROGRAMME MANAGEMENT
AND GOVERNANCE
To understand governance and programme management
issues, in-depth interviews were conducted with key high-
level personnel in the Central Tibetan Administration’s
Department of Health (DoH) and allied departments such
as the Department of Religion (DoR), Department of
Education (DoE) and Department of Home. This section
also includes the perspectives of the settlement officers or
health executives of each settlement. Key personnel from
the Government of India’s national TB programme were
also interviewed to document existing policy perspectives
regarding services, challenges and opportunities in the TB
programme and management.
Excerpts from interviews with settlement officers
Organisation of Tibetan settlements
Each settlement is headed by a settlement officer,
who belongs to the Central Tibetan Administration’s
Department of Home. The settlements comprise 1,000
to 8,000 people and are divided into camps, also called
villages. The inhabitants of each village elect a leader.
The settlement officer heads a fully staffed office and is
accountable to the Department of Home. The settlement
officers and their staffs plan the policies for the settlement
as a whole with respect not only to economic matters but
also to socio-cultural ones. The settlement officer also uses
the prestige of his office to mediate disputes, but only if
efforts at the lower levels fail. Externally, he often acts on
behalf of his settlers in their dealings with Indian legal and
political officials.
A total of three settlement officers were interviewed in this
assessment. The settlement officer is the key coordinating
officer linking seven departments and three autonomous
bodies of the CTA. He is in charge of development,
welfare and health issues. One of the officers said that his
office spends around 30 percent of the annual budget that
GOVERNANCE AND PROGRAMME MANAGEMENT
3

27
manager to understand the organisation and structure of
the TB programme within the CTA’s Ministry of Health.
We also tried to understand the financing and funding
mechanism, the management of information for decision
making, the policy documents and guidelines upon which
the programme operates, the human resources situation
and the engagement with various stakeholders.
There is a central TB unit within the Ministry of Health,
staffed by three officers whose duties are not clearly
defined. There is no document stating any strategic plan
for TB. Well-documented strategies for improving case
detection, treatment adherence, and management of drug-
resistant TB (DR-TB), TB-HIV, paediatric TB cases and
migrant TB cases do not exist. The strategy for engaging
civil society, NGOs and private care providers is not
properly defined.
AlthoughtheTBControlProgramhasnospecificguidelines
for diagnosis and management of TB, DR-TB, TB-HIV or
paediatric TB cases, the DoH is following the RNTCP’s
guidelines. Detailed information regarding financing and
funding mechanisms could not be collected, although it
was stated that they prepare annual budgets with identified
sources available for the TB control programme.
Information for decision making
Every quarter reports are collected from different health
units and sent by email as attachments. There is a person
assigned for quarterly compilation of the information
received. Standardised forms for recording and reporting
are available, such as TB treatment cards, a treatment
register, a laboratory register and quarterly reporting forms.
The compiled results are not issued by the central unit
and thus are not available in the public domain; however
the central unit staff said that they are in the process of
setting up a system to make the results available. Thus
there is currently no mechanism for dissemination of
reports or generation of feedback. The results are not being
analysed critically or scientifically to identify gaps in the
implementation of the programme. Thus there is poor use
of information for effective decision making.
Human resources for health
All CTA staff are governed by the HR policies of the
Planning Commission. However, HR-related issues such as
training, transfer and posting, incentives, and performance
appraisal need further deliberations. Training schedules
depend on the external funding available. As regards
salaries, they are paid on time. In addition, the staff also
receive a medical allowance, travelling allowances and per
diems according to CTA policy.
Areas such as monitoring and supervision and regular
programme reviews need more attention. There is no
initiative to establish linkages with the RNTCP, private-
sector practitioners, traditional medicine practitioners,
NGOs or other ministries.
Department of Education
There are four different types of schools depending on the
source of funding: individuals and sponsors, the Tibetan
Homes Foundation, the Government of India and the Snow
Lion Foundation. Every school has a clinic, which is visited
by medical doctors. In each school, there are trained health
workers, a nurse, a warden who recognise illnesses and
refers the child to the school doctor. Regular annual health
check-ups for all students are provided after vacation. This
is carried out by the DoH through its team of doctors. TB
screening is also done as part of the health check-up but
not systematically. Children who require specialised care
at a higher level are sent to Delek Hospital or to India/
Nepal where they have a reception centre.
Awareness talks are organised weekly or monthly in
schools by the school nurse or doctor. Sometimes they call
in external resource persons. In school assemblies, nurses
or teachers speak on health issues including TB for around
15-20 minutes.
In the DoE, there is a counselling cell with a chief
counsellor and counsellors for each zone. The counsellors
visit schools, talk to students on various topics such as life
skills, personal development and academic growth, goal
setting, decision making, substance abuse, making healthy
choices, preventive care etc.
However, the mechanism for recording and reporting is not
well articulated. The reporting of health-related events in
schools to the DoH is not formalised.
Governance and Programme Management

28
28
Delek Hospital, Dharamshala, which has been providing
exemplary TB care to the Tibetan population across all
settlements, was established in 1971. The CMO, Dr Testing,
is a renowned TB specialist, who has been guiding TB care
at Delek since 1987. The hospital administrator oversees
the day-to-day administration, and the CMO oversees the
medical care. The hospital has a daily OPD of 50-60 patients.
About 15 percent of these patients are non-Tibetans.
The TB wing is located separately from the main hospital
building and has a separate TB ward for isolation of
infectious TB cases.
Legal entities
All three DoH hospitals are registered as Societies under
the Indian Societies Act and have independent legal
existence. The Mundgod and Bylakuppe hospitals are also
registered as Clinical Establishments under the Karnataka
government and have unique identities for linkage with
the RNTCP’s Nikshay web portal; they may therefore be
deemed as Indian NGO hospitals for linkage with RNTCP.
The PHCs and health clinics are a part of the TVHA and do
not have a separate legal identity.
Delek is also registered as a Society and is distinctly
autonomous in its administration and funding, yet it works
under the auspices of the DoH. It has a nine-member Board
of Directors, which is chaired by the Health Kalong.
Staff roles and responsibilities vis-à-vis TB care
TB care is provided by doctors and designated nurses along
with lab technicians, pharmacists and X-ray technicians at
hospitals and at Bir PHC, except at Mundgod, where there
was no doctor or TB nurse at the time of the survey.
Training and supervision
All doctors and TB nurses at DoH facilities have been
trained at Delek Hospital. The doctor at Bylakuppe hospital
4.1 TUBERCULOSIS SERVICE DELIVERY AT DOH
FACILITIES AND DELEK HOSPITAL
1. Following is a summary of findings of on-site visits to
the following DoH health facilities:
2. Doeguling Tibetan Resettlement Hospital at Mundgod
3. Tso-Jhe Khangser Hospital at Bylakuppe
4. Dekylling Hospital at Dehradun
5. Tibetan PHC at Bir
6. Delek Health Centre at McLeod Ganj
Delek Hospital at Dharamshala
DoH Hospitals provide health services to a population
rangingfrom5,000to16,000;thedailyOPDis50-100.They
are equipped with basic diagnostic and treatment services
such as an OPD, in-patient wards for males and females,
laboratory, X-ray machines, dental unit, maternity ward,
TB isolation ward, pharmacy, physiotherapy, ambulance
services, and free immunisation. The daily management of
the hospitals is supervised by the hospital administrator,
while the medical division is headed by a chief medical
officer (CMO). The staff members are appointed by the
DoH per Tibetan Voluntary Health Association (TVHA)
staff rules and regulations.
Tibetan primary health centres (TPHCs) provide a wide
range of treatment facilities, including OPD consultations,
dressing room, pharmacy, laboratory, delivery room,
immunisation, ECG, X-ray, dental care, and physiotherapy,
24-hour emergency services. The settlement officer
supervises the daily management of the PHCs, and the
staff members are appointed by the DoH per TVHA staff
rules and regulations.
Health Clinics are present in several scattered Tibetan
settlements. These health clinics are managed by nurses
or community health workers. Some of them have doctors
who visit every week or two weeks. Their administration
is under the local settlement officers.
ASSESSMENT OF SERVICE DELIVERY
4

29
has received RNTCP modular training at the National
Tuberculosis Institute in Bengaluru.
All hospitals presently receive supervision from Dr
Lobsang of the DoH. At present, there is no fixed schedule
for supervisory visits; feedback is mostly provided verbally
or telephonically and there are no records of compliance.
At Bir PHC, the doctor and nurse have not had formal
training on TB.
At Delek Hospital, TB care is provided by two doctors
and one designated nurse along with a lab technician, a
pharmacist and an X-ray technician. The doctors have
received RNTCPmodular training; one doctor has received
programmatic management of drug-resistant TB (PMDT)
training, and one lab technician has undergone 10 days’
RNTCP training.
Delek Hospital functions as a nodal centre for the training
of doctors, nurses and lab technicians working in other
Tibetan health establishments, including DoH hospitals,
PHCs and health clinics. Health staff from schools and
monasteries also receive training at Delek.
There is no formal supervision and monitoring mechanism
in place presently.
Knowledge about TB and access to
TB policies and guidelines
Doctors and TB nurses have good knowledge of policies
and guidelines for management of TB per DoH/WHO
and RNTCP. They are also well aware of points on which
patients should be counselled, such as cough hygiene,
nutrition and identification of drug side effects and about
common drivers and co-morbidities ofTB, such as diabetes,
HIV infection, smoking, alcohol, and malnutrition.
Hard copies of guidelines are available at all facilities
surveyed, except at Dekylling Hospital, Bir PHC and
Delek Health Centre.
TB diagnosis
Sputum microscopy and X-ray facilities are available at
all hospitals visited by the team, including Delek Hospital.
CBNAAT equipment is also available in all facilities, but
it is not yet functional at Dekylling Hospital. At Mundgod
and Bylakuppe, upfront drug-susceptibility testing (DST) is
done for all sputum-positive cases, and at Dekylling select
cases are given the option to get DST from government
or private facilities. There are delays in diagnosis and
initiation of treatment, due to non-availability of a doctor.
Sputum microscopy and X-ray facilities are available at
Bir PHC.
Contact tracing is always done, especially among
schoolchildren, monks and nuns. The hospitals also
collaborate with the DoH to conduct active case-finding
(ACF) in Tibetan schools and monasteries every year.
Laboratory infrastructure
Lab facilities at four major hospitals were reviewed (Delek,
Bylakuppe, Dekylling and Mundgod), one PHC (Bir), one
school (TCV Upper Dharamshala) and one monastery
hospital (H. Poitner, Bylakuppe).
Sputum microscopy is done routinely along with other lab
investigations. Separate areas are demarcated for sample
collection and smear preparation. There is provision for
adequate water supply, and generators are available for
uninterrupted power supply.
Standard operating procedures (SOPs) for sputum staining
and smear grading were displayed at Delek Hospital, Bir
PHC and TCV Dharamshala, all in in the Kangra district.
There was sufficient supply of slides, immersion oil,
smearing and staining equipment and readymade stains for
Ziehl–Neelsen (ZN) staining. Facilities are using cleaned
glass injection vials for collection of sputum samples.
Lens tissues, filter papers for straining stains, and slide
boxes for keeping slides for EQA are not being used.
Cotton balls of surgical spirit are lighted for fixing the
stains.
All labs maintained good order and cleanliness and had
waste containers with lids. Disinfectants are available;
Lysol/ hypochlorite solutions are available but they are
not being used for disinfection of sputum cups, and staff
are not aware of their concentration and proper dilution
process. There is provision of segregation of bio-medical
waste (BMW) and linkage with collection agency at
Delek, Dekylling and Bir. Lab waste is disposed of with
general waste, burnt in open pits, at TCV UD, Mundgod
and Bylakuppe.
All facilities have at least two microscopes; one is usually
kept as spare. There is no system for annual maintenance
contracts at present. DoH hospitals have fluorescence
microscopes, but they have never been used.
Lab technicians having formal training in sputum
microscopy were available in all labs, except at H. Poitner,
Bylakuppe, where several volunteer monks do lab duty on
a rotation basis and have been trained on the job.
Presently, there is no mechanism of internal quality control
or external quality assurance. RNTCP staff collect data
from some centres but no on-site evaluation/randomized
blinded re-checking records were seen.
Assessment of Service Delivery

30
Two types of lab registers were seen: two sputum
examinations for diagnosis were entered in the RNTCP lab
register and one to three sputum examinations for diagnosis
and follow-up of TB cases on daily DOTS were entered in
the facility’s own lab register. The names and addresses
written in the TB laboratory register are generally legible
and the practice of writing positive results in red and
negative in blue/black is followed. Monthly and yearly
results are not summarised.
The labs are mostly well-lit and ventilated. In Delek
Hospital, lab work is done in a closed, air-conditioned
environment, and windows are not kept open. Some
patients may be collecting sputum samples in toilets.
These conditions need to be changed. A Bio Safety cabinet
is needed for containment of infections.
Treatment of TB
During visits, there was one case each on daily DOT at
Mundgod and Bylakuppe; eight RNTCP DOTS, four daily
DOT, two MDR and one XDR cases at Dekylling Hospital;
and 25 daily DOT and 10 MDR cases at Delek Hospital.
There were four cases on daily DOTS at Bir PHC.
There were 26 case files of ongoingTB cases, including five
MDR cases at Mundgod, which were taking unsupervised
treatment.
Sputum microscopy, X-ray facilities and CBNAAT are
available for diagnosis of TB cases in Tso-Jhe Khangser
Charity Hospital, Bylakuppe. But there are few cases on
treatment as many TB cases are currently managed by
private doctors at hospitals linked to local monasteries as
well as by Indian primary health centres.
Mild to moderate side effects of the TB drugs are managed
locally, but drugs are stopped and Delek doctors are
consulted in case of severe side effects.
Separate TB wards are present at all hospitals visited by
the team. After diagnosis, infective patients are admitted
in TB wards till their sputum samples are negative for
MTB on microscopy/culture. Thereafter they are referred
to hospitals, PHCs and health clinics near their place of
residence for continuation of treatment.
Multidrug-resistant TB (MDR-TB) cases are advised to
come back at three-monthly intervals for follow-ups. The
hospital doctors are adept at managing minor to severe side
effects.
Management of drug-resistant tuberculosis
Tuberculosis isolation wards are present in all the hospitals
visited by the team: Delek, Dekylling, Bylakuppe and
Mundgod.
PMDT-trained doctors are available only at Delek
Hospital. The WHO DR-TB module was available at
Delek Hospital. There is no documented policy by the
DoH regarding management of DR-TB cases. Presently
there is no formal DR-TB committee to oversee the care of
DR-TB cases. At Delek Hospital, daily morning meetings
are held to take necessary decisions on case-by-case basis.
The other hospitals are in constant touch with Delek to
consult on any issues regarding DR-TB cases in their care.
There is no DOTS Plus Register. Treatment cards of DR-
TB cases are available. They are updated infrequently—at
Delek when patients come for three-monthly review, and
at other facilities most of the cards had incomplete records.
Patients are procuring supplies at three-monthly intervals
and many take unsupervised treatment at home. There is a
lack of community DOT providers.
The wards are generally clean, well-lit and ventilated. They
are away from other wards, especially in Bylakuppe and
Mundgod. The wards are spacious, except in Dharamshala.
In Mundgod and Bylakuppe, there is plenty of space, with
patients being kept in separate rooms built around central
courtyards and surrounded by vast open spaces. They are
ideal to be considered to serve as DR-TB wards for DOTS
Plus sites by the Karnataka government under private-
public mix schemes). Admitted cases are given a high-
protein diet, including milk and eggs.
Facilities for hand washing with water, soap or hand wash
solution to be used by doctors, health workers and patients
are available, and hopefully they are also used. The wards
are wet mopped once a day. There was no display of any
IEC material on cough hygiene in the ward. The measures
for safe collection and disposal of sputum were inadequate.
Patients were sometimes advised to collect sputum in
plastic containers and flush the same.
Information for decision making
All DoH hospitals have sputum slips and lab registers for
sputum microscopy. Treatment cards are available. TB
register or DOT register, DR-TB lab & treatment registers,
and transfer forms or registers are not available. Records
of EQA and BMW disposal are also not available. Excel
sheets with patient-wise data are being maintained and
sent electronically to DoH on a quarterly basis, but regular
reports on case finding, case holding and outcomes are not
being prepared.
Bir PHC has sputum slips and lab registers for sputum
microscopy. Treatment cards are available. A DOT register
is maintained. DR-TB lab is not required, and transfer
forms or registers are not available. Records of EQA and
BMW disposal are also not available.

Assessment of TB Care and Management Services in Tibetan Settlements in India

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