The government must establish a department of public health soon

It will give the failing discipline the priority, energy and momentum it urgently requires

To eliminate tuberculosis by 2025, a decision to integrate the two vertically implemented programmes — tuberculosis with HIV/AIDS — was taken in March, and an expert committee was constituted to provide the operational strategies for it. The argument for this integration is unquestionable. When HIV/AIDS claimed 30 million lives in the 1990s, it was declared a global emergency and several countries swung into action to contain the epidemic.

India, with the third highest number of HIV infections, established the National AIDS Control Organisation (NACO) in 1992 under the ministry of health and family welfare. NACO, however, had operational freedom. This enabled it to innovate and work with 29 developmental partners, people with HIV and communities most vulnerable to infection, state governments, media, judiciary, medical colleges, research institutions and civil society. This led to a 67% decline in HIV incidence in India, one of the highest rate of decline in the world.

Since 2014, however, the march has been halted: Shifts in strategy and reduced funding have weakened NACO, resulting in HIV incidence rising in some states.

With the introduction of the Directly Observed Treatment Shortcourse (DOTS) to treat TB in 1995, the World Health Organization (WHO) in India wanted India’s TB programme to be provided a Naco-like instrumentality. The ministry strongly resisted it as the critical nature of the disease made it vital for it to be under the direct supervision of the Directorate General of Health Services for speedy implementation. The programme was scaled up, but lost its momentum with its integration with the National Rural Health Mission in 2005, which accorded a higher priority to reproductive and child health. Infectious disease-control programmes, including TB, fell in importance, resulting in the annual TB incidence remaining stagnant at 2.8 million, with 0.43 million deaths. Worse, projections indicate that by 2022, India will account for 42% of the world’s multidrugresistant (MDR) TB, up from 16% today.

These are extraordinary numbers and needed a sharp response, which led to the merging of TB with NACO programmes. Around 28% of HIV patients get TB infection and about 4% of TB patients acquire HIV.

While the recommendations of the expert committee to integrate TB with HIV is awaited, several issues need to be carefully considered: simple integration of the TB programme with the NACO programme design — including national, state and district control programmes, technical support units, targeted interventions, funding patterns, bringing the patients centrestage — and making district TB officers-incharge of both programmes may not be that easy to implement, particularly at the district levels.

Balancing the various demands of policy within a seemingly homogenous entity is a challenge, globally too. Departments are constituted and reconstituted in keeping with dynamic needs. This makes implementation design as critical as the policy itself as it needs to be nimble to reflect the changing policy environment.

History shows two policy blunders made in the past. The reduction of malaria from 75 million to 2 million cases in 1972 led to the malaria workers cadre being abolished and reconstituted as multi-purpose workers. Today, malaria continues unabated. Reduction in leprosy incidences resulted in leprosy units being made responsible for HIV/AIDS programmes at the district level, which led to leprosy cases going up.

The lesson here is that the guard cannot be lowered. The question is: are we repeating a tragedy? Maybe not and such an integration is the way forward for now, as TB is a co-infection of HIV, and there are associational linkages. Yet there are substantial asymmetries, such as funds flow, skill mix, institutional linkages, target population profiles etc need to be managed skillfully so one does not damage the other.

For example, the strategic intervention that led to NACO’S success was differential planning based on surveillance/incidence data that track location and population affected. We have no idea of TB incidence and the prevalence estimates are weak and unreliable, a problem that is compounded by the shortage of district TB officers in some states.

The huge infectious disease burden and our failure to make the epidemiological transition should be used as an opportunity to revamp the institutional architecture and address the long-pending demand for a department of public health.

The countries that have succeeded in disease control have strong public health cadre and outreach programmes that are separate from long-term care, besides hospitals and medical education as the demands and skills needed for institutional care and public health are hugely diverse.

With leadership from experts, a department of public health will give the failing discipline the priority, energy and momentum it urgently needs.

In short, India needs to treat the disease, not the symptoms, for sustainable outcomes.