World Health Organization, Geneva, 1992:

The review of the National Tuberculosis Programme (NTP) of India was carried out in 1992 by a team representing the Government of India (GOI), the World Health Organization and the Swedish International Development Agency (SIDA). The purpose of the review was to evaluate present policies and practices, analyse their adequacy to reduce the tuberculosis problem and recommend organizational, technical and administrative measures to improve the programme. The review team analysed the available documents including epidemiological data and reports of previous evaluations of the programme, discussed with officers of major institutions involved in disease control and in training, and made field visits in three States (Gujarat, Uttar Pradesh and Tamil Nadu) to assess the programme at the State, District and Peripheral levels. The National Tuberculosis Programme (NTP) was formulated in 1962 with major objectives of finding cases among the self reporting chest symptomatics, providing effective treatment near their homes, giving priority to smear positive patients and providing free diagnosis and treatment facilities. Human and financial resources are provided by Govt. of India and the States.

Situation Analysis: The constraints and shortcomings observed in the programme are giving low priority to NTP in allocation of funds and political commitment, wide gap between expectations and achievements, no change in the trend of tuberculosis, and threat of HIV infection aggravating the problem. The programme is integrated with General Health Services (GHS); however, the population growth and the proliferation of public health services has made the districts unwieldy for effective supervision by a single District TB Centre. The present management structure at national level requires strengthening, reorganisation and training at the state level. Improvement in the methods and management of Case-finding is needed as there is undue dependence on X-ray and clinical examinations. Standards of carrying out microscopy are low and laboratories are not well equipped. The treatment regimens are too many and standard regimens are ineffective and of long duration. Short Court Chemotherapy (SCC) implementation is very slow. The drug supplies are occasionally interrupted by lack of timely funding and of buffer stock. The Health Workers (HWs) are not utilised to prevent defaulting and to achieve treatment completion. The cure rate as the main indicator of programme efficiency is not available due to lack of followup examinations. The recording and reporting is complex and seriously deficient. Health infrastructure in metropolitan and urban areas is inadequate. The findings of previous programme evaluations have not been applied nor has adequate use of the results of operations research for the improvement of programme has been made.

However, the basic strengths of the India's TB Programme are considerable. The objectives on which the programme was established thirty years ago integration, decentralization, free services, priority to treatment of infectious cases are still valid today. They provide a sound revitalization of the national TB strategy. An updated and strengthened programme can expect to reduce the magnitude of the problem by about half in each 10-15 years. This will require political commitment, initial investment and strong leadership.

RECOMMENDATIONS Formulation of an executive task force at apex level, upgrading the central tuberculosis control unit in the Directorate to enhance the efficiency and effectiveness of the NTP. Quality of sputum examination to be improved by multiple smear examination, ensuring quality of microscope, training and quality control. Giving priority to smear positive cases, adopting SCC regimens, establishing criteria of treatment completion and cure. Ensuring an uninterrupted supply of drugs of good quality, revise the registration and notification system of NTP and giving due emphasis to cohort analysis. Policy of decentralization of treatment services closer to the community. Strengthening of administrative structure at the sub district level by providing Medical Officer, Treatment Organizer and Laboratory Supervisor to facilitate decentralization of supervision and tuberculosis programme. Development of training capabilities by utilizing state training facilities, medical colleges, public health institutes and voluntary agencies. In the light of the recommendations and concerns expressed by the Central Health Council, a revised strategy for NTP has been implemented in some selected areas of the country with the World Bank assistance. Operations Research must be carried out as an integral part of the revised NTP to evaluate performance and obtain baseline epidemiological information to measure reduction in the risk of infection.