Panchayats Need Funds To Become TB-Mukt

Besides, TB is a ‘social’ disease in that the malnourished, living in areas with poor hygiene, are more vulnerable to the disease. The lack of nutrition and the risk of contracting TB are interrelated, research found, as IndiaSpend reported in October 2022. The lack of nutrition makes a person more susceptible to TB, while having TB increases the chance of malnutrition. Malnourished patients also find it harder to recover from TB. Addressing these determinants will need a more extensive approach.

Further, a 2022 study in Karnataka found that half of the early TB fatalities (that is, TB patients who succumbed within two months of diagnosis) occurred in the first fortnight after diagnosis, as IndiaSpend reported in October 2023, making grassroots interventions all the more significant.

A letter from the secretary, Ministry of Panchayati Raj to states describes the initiative as an effort “to empower the Panchayati Raj Institutions to realise the extent and magnitude of problems associated with TB, take necessary actions towards addressing these problems, create healthy competition amongst panchayats to eliminate TB and to publically appreciate their contributions”.

Involving the rural local bodies in health services delivery is not a new idea. When panchayats were conceptualised, they were expected to prepare plans and implement schemes to ensure social justice and economic development in relation to 29 areas listed in the Constitution’s Eleventh Schedule, including health.

By engaging the panchayat, the government can tap a grassroots authority that is familiar with the real issues of the community and hence, well placed to ensure that health services are delivered to the most vulnerable populations such as women, the elderly, and daily wagers employed under the Mahatma Gandhi National Rural Employment Guarantee Act, said T. Raghavendra, director of North Karnataka operations at the Karnataka Health Promotion Trust (KHPT).

Since 2021, the KHPT has been helping Karnataka’s Department of Rural Development and Panchayati Raj implement the Graama Panchayath Arogya Amrutha Abhiyaana (GPAAA), a programme that aims at converging the efforts of different stakeholders at the village level--individual health functionaries like the ASHA worker, the village health, sanitation and nutrition committee, self-help group members, youth club members, etc.--to realise the vision of health for all.

“To involve the panchayat is to decentralise TB care, and thereby, help early diagnosis, monitoring the adherence to treatment, the active surveillance of contacts and ensuring microbiological cure, thereby arresting spread,” Lancelot Pinto, a consultant respirologist with the PD Hinduja National Hospital and Medical Research Centre, Mumbai told IndiaSpend.

Decentralisation can help reach out to people who have fallen through the cracks in the care cascade. The TB care cascade covers access to testing, successful diagnosis, registration for treatment, treatment success, and recurrence-free survival. In India, for every 100 patients who have TB, a paper published in PLOS One estimated that 68% access TB tests, 57% are diagnosed with TB, 50% register for treatment, 43% complete the course, and only 37% have a recurrence-free survival. Essentially, at every step of the care cascade, some patients drop out.

States were given a target of freeing 10% panchayats of TB in the initiative’s first operational year and 30% in the second year, according to a state tuberculosis officer interviewed by IndiaSpend, who did not want to be named.

Nalini Krishnan, director of the Resource Group for Education and Advocacy for Community Health (REACH), Chennai, a not-for-profit working on tuberculosis since 1999, said milestones are a good measure of success in a public health initiative and are part of the steps to end TB. But Pinto pointed out that “incentivising eradication with goals carries the risk of making the same mistakes we made in the fight to eradicate malaria.

“Since a significant proportion of TB is reactivation of latent disease, and close to half of all Indians might be latently infected, one can only truly be ‘TB-Mukt’ if the reservoir of infection has been eradicated,” said Pinto.

That, he said, “is a lofty goal, and in the bid to reach a milestone, there is a high probability that standards might not be adhered to”.

States pick low-hanging fruit to achieve first-year target

While Prime Minister Narendra Modi announced the programme on World TB Day in March 2023, in many large states, the scheme was practically kicked off about five months later on Independence Day last year. With the TB calendar ending on December 31, 2023, to achieve the first year’s target, states had to resort to picking the low-hanging fruit--that is, target areas known to report fewer TB cases.

“Our approach in the first year of the TB-Mukt Panchayat initiative has been to identify and target pockets which are known to not have reported tuberculosis, probably because the people are healthier,” Hitesh Verma, state TB officer for Haryana, told IndiaSpend.

Verma believes the next year will be more challenging “because the health system will have to work that much harder to create awareness amongst and involve the panchayati raj representatives”.

IndiaSpend learned that in 2023, 8% panchayats across Maharashtra (2,249 of 27,850) became eligible to be certified TB-free, 14% panchayats in Haryana (579 of about 4,200) were verified, and about 22% panchayats (700 of 3,200) qualified to be TB-free in Himachal Pradesh. In Karnataka, where the panchayats have had a head start in tackling TB because of the GPAAA, only about 13% (750 of 5,957) were TB-free last year.

Now in its second year, the performance of the TB-Mukt Panchayat initiative will be pivotal to decide if the programme is on course to free villages of TB. Further, the programme targets a TB case notification rate not exceeding one case per 1,000 population, among other indicators (see box), but the World Health Organization (WHO) defines the global elimination of TB as a public health problem as less than one case per million people.

Targets For A TB-Mukt Panchayat

Source: How can TB Mukt Panchayat initiative contribute towards ending tuberculosis in India

Insufficiently motivated leaders are obstacles in eliminating TB

The TB-Mukt Panchayat programme is being implemented by the health and panchayati raj ministries. In Maharashtra, state TB officer Sandeep Sangale told us, district TB officers were told to involve field staff such as auxiliary nurse/midwives (ANMs) and ASHA workers in the awareness initiative. The department conducted state and divisional-level workshops in coordination with both departments for officers and staff, and panchayat members were trained on TB and the TB-Mukt panchayat initiative at the block level in most districts.

In practice, “a lot depends on the motivation levels of the district tuberculosis officers”, said Verma. “In Haryana, some districts like Ambala, Bhiwani, Kurukshetra, Panchkula, are performing very well, the others are on the way.”

Rakesh P. Suseela, senior technical advisor to the International Union against TB & Lung Diseases, South East Asia Office, New Delhi, conceptualised the TB-Free Panchayat in 2017, and helped Kerala implement it through the Kerala TB Elimination Mission. The presence of an efficient officer to advocate for TB elimination at the primary health centre and good leadership in the panchayat helped, said a paper he co-authored on the implementation of the Mission. The paper found that local governments that had performed well in other health programmes performed well in TB elimination too.

Essentially, eliminating TB in less developed areas where the local government and primary health structures are weak will depend on strengthening the system, said Suseela.

“TB will either sink or sail with the system,” he said.

Setting easier goals than the global WHO targets could mislead

The United Nations Sustainable Development Goals (UN SDG) for health include ending the TB epidemic by 2030. In terms of targets, this means a 90% reduction in the number of TB deaths and an 80% reduction in the new cases per 100,000 population per year, as against the number of deaths and new cases in 2015.

India aims to achieve this UN SDG target by 2025, that is, five years ahead of the global target. India’s containment of TB is more or less on par with the 2% fall in the incidence rate globally, IndiaSpend reported in May 2023. However, the decline is well below the 10% drop the WHO had targeted to be achieved by 2025, and the 17% decline projected for the following decade, to end TB by 2035.

Freeing a village of TB, by achieving a TB case notification rate not exceeding 1 per 1,000 population, cannot technically be equated with ending the TB epidemic or with the global elimination of TB as a public health problem.

Suseela pointed out that government certification should neither be considered nor construed to be epidemiological.

“Overemphasis on certification carries the risk of defeating the purpose, as the ‘TB-free’ tag may lead to complacency,” he said. “Certification is just to motivate panchayats to work towards ending TB.”

The Kerala TB Elimination Mission focused more on the process of achieving TB Free Panchayats than on certification, added Suseela. “The programme addressed the community ownership for ending TB, decentralised surveillance and planning, promoting local solutions, serving socially vulnerable individuals, supporting patients through their treatment and addressing social determinants through multi-sectoral coordination at the village level.”

Grassroots challenges in eliminating TB from panchayats

In Maharashtra, the state TB officer Sangale said, “When we started to monitor panchayats for the six indicators, we found that most [panchayats] fell short in the number of presumptive TB patients required to be examined because they had fewer TB cases.”

Panchayats are required to examine at least 30 presumptive TB cases for every 1,000 people.

“So this year, we are targeting examining at least 3% of the population,” said Sangale.

Another potential challenge in implementing the TB-Mukt Panchayat initiative, according to a recently-published study in The Lancet, is the design of the online case-based surveillance system of the National Tuberculosis Elimination Programme, Ni-Kshay. It doesn’t capture panchayat-level data.

“Deriving the panchayat-level data on the indicators retrospectively will not be easy and is subject to errors,” study co-author Suseela told IndiaSpend.

In Kerala, a separate Excel-based Management Information System was deployed to capture the data by panchayat. Subsequently, the panchayat-wise data on presumptive TB patients’ examination, case notification, drug-resistant cases, contacts’ investigation and quarterly treatment outcomes were released for review by the Panchayat Task Forces and the District TB Elimination Boards chaired by the district collector.

How extra funds could help free panchayats of TB

No resource allocation has been made to the TB-Mukt Panchayat initiative.

“Panchayats are expected to include tuberculosis in their panchayat development plan, and budget for screening activities and nutritional hand-outs in their programme implementation plan,” said Raghavendra.

In Karnataka, Raghavendra said that in some panchayats, the task force is taking the lead in this, even budgeting for the procurement of a TB diagnosis health kit.

However, Pinto is of the firm belief that decentralisation can only work with adequate funds. “Without the tools (molecular diagnostics) for early detection, an uninterrupted supply of drugs (which has been a challenge in recent times) and the funds to conduct active surveillance, which is manpower- and resource-intensive, it is unlikely that the results will change dramatically,” he said.

In Kerala, some of the volunteers who helped to find active cases, collect and transport specimens, etc. were paid, said Suseela. Others such as treatment support groups were not.

Allocating extra funds to the TB-Mukt Panchayat initiative would definitely help improve implementation, said Gopal Beri, state TB officer for Himachal Pradesh.

Alluding to India’s low budgetary allocations to health, Pinto also said, “TB is also a social disease in as much as it is a disease caused by a germ, and the poverty, malnutrition and living conditions that foster the disease will not change unless there is a significant increase in resource allocation.”

‘Social’ diseases need a social plus medical treatment approach

In the light of the social ramifications of TB, Mallika Biddappa-Tharakan, knowledge management lead at KHPT, proposes that any initiative to treat the disease should expand from being just a medical approach to also include a social approach.

In that sense, K. Karthikeyan, thematic lead for TB at KHPT, pointed out that the indicators to certify a panchayat TB-free rightly combine clinical and social requirements--with the requirement for the payment of at least one installment of direct benefit transfer for nutritional support and distribution of additional nutritional support in the form of donor-initiated food baskets.

Karthikeyan is of the firm belief that the gram panchayat should also be included in the delivery of other health services.

“Eventually we should think beyond TB at the panchayat level,” he said. “Gram panchayats can help address other diseases as well as social issues. We first just need to strengthen the structure, for which TB is the starting point.”

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