In an attempt to meet its ambitious target of eliminating tuberculosis by 2025, the government has moved to further align the Revised National Tuberculosis Control Programme with the National AIDS Control Organisation.
The Ministry of Health and Family Welfare issued an order on March 28 directing that the Revised National Tuberculosis Control Programme and the Central TB Division, that have so far been under the Directorate General of Health Services, be transferred to the Department of Health and Family Welfare under the charge of the additional secretary and director general of NACO.
The notification says that the purpose of the move is to optimise resources and use NACO’s successful approach of working with community based organisations in the HIV control programme.
However, both programmes will retain their structure and identity.
“There is no merger of the two programmes,” said Alok Saxena, joint secretary of NACO. “It is only that the RNTCP, like NACO, is now placed under AS&DG NACO. Both the programmes will continue to have their own identity.”
The need for collaboration
Since 2001, India has developed and updated joint frameworks for the collaborative activities for HIV and TB control. These activities have included joint trainings of staff under the two programmes, developing mechanisms for controlling infections such as intensified TB case finding at antiretroviral therapy centres for HIV patients, and HIV prevention education for patients with presumptive or diagnosed TB.
However, India continues to have the highest burden of TB in the world. In 2016, India had an estimated incidence of 2.8 million cases and more than 4,00,000 people died of the disease. There has also been a rise in the number of multi-drug resistant TB across the country, making the disease more difficult to treat. TB is an opportunistic infection that affects HIV patients whose immune systems are compromised. According to Saxena, the largest number of deaths of HIV patients in India is due to TB.
Even though the Revised National Tuberculosis Control Programme is one of the oldest national disease control programmes in the country, India’s TB control is still faltering when it comes to preventing, diagnosing and treating patients. A report released by the Stop TB Partnership and Médecins Sans Frontières in July last year highlighted that the TB programme uses outdated diagnostic techniques, suffers from repeated medicine stock-outs and lacks capacity to counsel patients.
On the other hand, India’s HIV control programme has had a history of successful engagement with community organisations that has helped in bringing down the incidence of HIV and AIDS, including the establishment of Integrated Counselling and Testing Centres where counsellors explain the disease, how drugs should be taken and how the spread of the disease can be prevented.
“Both the programmes should learn from each other,” said Saxena. “NACO has strengths in community engagement and works with civil society for a bottom-up approach and a linear and very fast decision making. RNTCP has the strength of engagement with the private sector, notification, which NACO can learn from RNTCP. Both can leverage equipment, infrastructure and machinery from each other.”
According to Saxena, the health ministry has already told states administrations that in districts where NACO does not have a presence, district TB officers should also be designated as district HIV officers.
Sunil Khaparde, the deputy director general for TB in the Directorate General of Health Services declined comment.
Health activists working with tuberculosis patients welcomed the health ministry’s move.
“I think it is a good move,” said Blessina Kumar, CEO of the Global Coalition of TB Activists. “There were lot of components being missed out in the RNTCP as a vertical programme. It has been a very medicalised programme. So a lot of non-medical aspects like welfare of affected communities and key populations, human rights of patients have been difficult areas for RNTCP to look at. But these are the strengths of the HIV programme. So one hopes that those will be translated into the TB programme as a well.”
Global health and bioethics researcher Anant Bhan said, “Importantly, the access movement has worked strongly globally and in India on the access to medications issue in HIV, and perhaps could take advantage of this planned merger to also put pressure on the government for better access to TB drugs, especially for new medication.”
However, the heath community is still looking for clarification of how the alignment of the two programmes is actually going to work. Kumar said that there are questions about how the programmes be implemented separately, what happens to the budget allocations and what the reporting mechanisms will be.
“The funding for both will continue to remain as is,” said Saxena. “Maybe two years down the line, we will see how it works. What is important is that we build synergies rather than the two programmes working in silos, so that we optimise our efforts and resources.”
Said Bhan, “Activists and civil society should continue to critically follow this announcement to ensure that the merger does not negatively impact both the TB and HIV programs, as well as the health system, in terms of access, continuity of programs, and particularly the issue of funding.”