A study of policy process and implementation of the National Tuberculosis Programme in India
TB, a major public health problem in India since the 1900s, has a current prevalence of 14 million and an estimated annual mortality of 500,000 persons. Nation-wide government sponsored anti-TB public health measures introduced in 1948, developed into the National TB Programme in 1962. Despite gains, implementation gaps between programme goals and performance, over 35 years, have been of a magnitude sufficient to cause concern. This study aimed to understand explanatory factors underlying the implementation gap. A policy analysis approach was adopted, focusing on the policy process and specifically on implementation, at national, state, district and local levels. It undertook a historical review with a two-tiered framework covering the period 1947-97. In the first tier the historical narrative is woven around a framework of context, content, process and actors. The nature of the problem and policy relevant technical dimensions of intervention measures are discussed, as are effects of pharmaceutical policies and financial resource flows on TB policy. The second tier applies a framework of implementation factors to national policy development and implementation at state and district level. Interviews were conducted with TB patients, elected representatives, front-line health workers, doctors, district and state staff, national programme managers, researchers and representatives from international agencies. Documents were reviewed. Thus the study incorporated an integrative bottom-up cum top-down approach. Findings highlight that interests of patients, medical and allied professionals, pharmaceutical and diagnostic industries and the state are interdependent, but often conflictual. Unequal societal relations affect not only the development and transmission of TB, but also the implementation of control programmes, particularly for the impoverished, among whom high levels of indebtedness due to the disease and difficulties accessing private services were noted. Techno-managerial approaches to TB control often mask societal and policy process factors accounting for the implementation gap. The importance of leadership, institutional development, capacity at the patient provider interface and accountability and need for sustained policies were noted, within an affirmative framework embodying social justice and safeguarding the interests of the majority of patients.