Role of Medical Colleges in RNTCP

Special Report
Indian J Med Res , February 2013;137: 283-294

Contribution of medical colleges to tuberculosis control in India under the Revised National Tuberculosis Control Programme (RNTCP):Lessons learnt & challenges ahead

Surendra K. Sharma1,*, Alladi Mohan2,*, L.S. Chauhan3,*, J.P. Narain4,*, P. Kumar5,*, D. Behera6,*, K.S. Sachdeva7,*, Ashok Kumar7,*,for Task Force for Involvement of Medical Colleges in the Revised National Tuberculosis Control Programme

1Department of Medicine, All India Institute of Medical Sciences, New Delhi, 2Department of Medicine, Sri Venkateswara Institute of Medical Sciences, Tirupati, 3National Centre for Disease Control, New Delhi, 4Formerly Director, World Health Organization Regional Office for South-East Asia (WHO-SEARO) for Sustainable Development & Healthy Environments & for Communicable Disease Prevention & Control, WHO-SEARO, New Delhi, 5National Tuberculosis Institute, Bengaluru, 6Postgraduate Institute of Medical Education & Research, Chandigarh & 7Central Tuberculosis Division, Ministry of Health & Family Welfare, Government of India, New Delhi, India

Writing Committee

Other Contributors (names listed alphabetically):

Agarwal Priyanka, Awadh N.T., Bansal Avi, Baruah S, Baruwa Pranab, Balasangameshwara V.H., Balasubramanian Rani, Bhardwaj A.K., Bhargav Salil, Chadha Sarabjit, Chaddha V.K., Chhatwal Manpreet, Da Costa A.L., Dash D.P., Dep Jaydip, Dhingra Saroj, Dhooria Harmeet S., Frieden T.R., Garg Anil, Granich Reuben, Gulati Vinay, Gupta Deepak, Gupta Dheeraj, Gupta K.B., Gupta K.N., Jaikishan, Janmeja A.K., Jawahar M.S., Jethani S.L., Jindal S.K., John K.R., Kalra O.P., Kalra V.P., Kannan A.T., Kayshap S., Keshav Chander G., Khushwa S.S., Kushwaha R.S., Kumar Vinod, Laskar B., Leela Itty Amma K.R., Leuva A.T., Maitra Malay K., Mesquita A.M., Mathew Thomas, Mundade Yamuna, Munje Radha, Nagpal Somil, Nagaraja C., Nair Sanjeev, Narayanan P.R., Paramasivan C.N., Parmar Malik, Prasad Rajendra, Phukan A.C., Prasanna Raj, Purty Anil, Ramachandran Ranjani, Ramachandran Rajeswari, Ravindran C., Reddy Raveendra H.R., Sahu S., Santosha, Sarin Rohit, Sarkar Soumya, Sarma K.C., Saxena P., Sehgal Shruti, Sharath N., Sharma Geetanjali, Sharma Nandini, Shridhar P.K., Shukla R.S., Singh Om, Singh N. Tombi, Singh Varinder, Singla Rupak, Sinha Neena, Sinha Pranay, Sinha Sanjay, Solanki Rajesh, Sreenivas A., Srinath S., Subhakar Kandi, Suri J.C., Talukdar Palash, Tonsing Jamie, Tripathy S.P., Vaidyanathan Preetish, Vashist R.P., Venu K.

Abstract

Medical college faculty, who are academicians are seldom directly involved in the implementation of national

public health programmes. More than a decade ago for the first time in the global history of tuberculosis

(TB) control, medical colleges of India were involved in the Revised National TB Control Programme

(RNTCP) of Government of India (GOI). This report documents the unique and extraordinary course of

events that led to the involvement of medical colleges in the RNTCP of GOI. It also reports the contributions

made by the medical colleges to TB control in India. For more than a decade, medical colleges have been

providing diagnostic services (Designated Microscopy Centres), treatment [Directly Observed Treatment

(DOT) Centres] referral for treatment, recording and reporting data, carrying out advocacy for RNTCP

and conducting operational research relevant to RNTCP. Medical colleges are contributing to diagnosis

and treatment of human immunodeficiency virus (HIV)-TB co-infection and development of laboratory

infrastructure for early diagnosis of multidrug-resistant and/or extensively drug-resistant TB (M/XDRTB)

and DOTS-Plus sites for treatment of MDR-TB cases. Overall, at a national level, medical colleges

have contributed to 25 per cent of TB suspects referred for diagnosis; 23 per cent of ‘new smear-positives’

diagnosed; 7 per cent of DOT provision within medical college; and 86 per cent treatment success rate

among new smear-positive patients. As the Programme widens its scope, future challenges include

sustenance of this contribution and facilitating universal access to quality TB care; greater involvement

in operational research relevant to the Programme needs; and better co-ordination mechanisms between

district, state, zonal and national level to encourage their involvement.

Introduction

Tuberculosis (TB) is a dreadful infectious disease with devastating social and economic consequences.

India is one of the high TB burden countries. More adults die from TB than from any other infectious

disease in India1. With its commitment to reduce the morbidity, mortality and disability due to TB and

eliminate it as a public health problem, the Government of India (GOI), after piloting the DOTS strategy

successfully from 1993-1996, had initiated the Revised National Tuberculosis Control Programme (RNTCP) adopting the DOTS strategy in 1997. Subsequently, the Programme had expanded to cover the entire population of the country in March 20062. In India, TB patients are managed by several healthcare providers involving diverse sectors from the government, nongovernmental organizations (NGOs) and the private and corporate sectors. Effective control of TB will be possible if all these sectors join together and work towards a common goal.

A substantial proportion of patients with TB are managed at medical colleges across the country. From

the TB control point of view, medical colleges, in both the government and private sectors are recognized

to occupy a key position with a unique potential for involvement with the RNTCP. To widen access and

improving the quality of TB services, involvement of medical colleges and their hospitals is of paramount

importance. Being tertiary care medical centres, large numbers of patients seek care from the medical

colleges. In addition, the role of medical college faculty in TB control as key opinion leaders and role models

for practicing physicians and as teachers imparting knowledge, skills and shaping the attitude of medical

students cannot be underestimated. There is a pressing need for all medical colleges to advocate and practice

DOTS strategy which provides the best opportunity for cure of TB patients. In addition, medical colleges

have the diagnostic facilities for extra-pulmonary TB (EPTB), human immunodeficiency virus (HIV)-TB coinfection, multidrug-resistant TB and extensively drugresistant TB (M/XDR-TB). Recognizing the potential

of involving medical colleges in TB control a decade ago, the RNTCP of GOI, for the first time in the world

conceived and implemented the unique experiment of involving the academicians who constitute the faculty

in the public health programme for TB control. A mechanism of National, Zonal and State level Task

Forces was conceived for the involvement of medical colleges, wherein the sole responsibility of participation

of medical colleges in DOTS strategy lies with the faculty of medical colleges, which perhaps made them

more responsive. Involvement of medical colleges in TB control: history and past activities Since 1997, concerted efforts have been made to involve medical colleges and their hospitals in the Programme when the first National Consensus Conference on TB was held in New Delhi3,4. This meeting was followed by two meetings in 2001 at the National Tuberculosis Institute (NTI), Bengaluru5 and the All India Institute of Medical Sciences (AIIMS) - World Health Organization, South-East Asia Regional Office (WHO, SEARO), New Delhi Meeting on the Involvement of Medical Colleges in TB and Sexually Transmitted Infections (STI) / HIV Control held at AIIMS, New Delhi6. Professors from over 35 prestigious medical colleges/institutes participated in these meetings and accepted RNTCP as a control programme with potential for a “remarkable success” in TB control in India and expressed their commitment to the Programme. In the meeting recommendations were made to consider medical colleges as an integral part of the RNTCP. As per these recommendations, it was envisaged that medical colleges will offer RNTCP diagnostic and treatment services, teach and carry out advocacy about RNTCP, and participate in implementation and monitoring of the Programme. The October 2002 National Level Workshop of Medical Colleges at AIIMS, New Delhi, was instrumental in developing the structure and processes required for the effective nation-wide participation of medical colleges in the Programme. Seven medical colleges located in the different zones of the country at New Delhi, Chandigarh (North), Jaipur, Mumbai (West), Kolkata (East), Vellore (South) and Guwahati (North-East) were identified as nodal centres and were requested to lead the initiative of participating in the Programme (Figs 1A and 1B). Nodal faculty members from these seven medical colleges, were trained at the national institutes [e.g., National Tuberculosis Institute (NTI), Bengaluru]. 

Structure of the National, Zonal and State Task Force

A Task Force mechanism at the National, Zonal and State level (Fig. 1A) was established. Subsequently,

there were consensus workshops in the States with medical colleges which further detailed the exact mechanisms for collaboration. This formed the basis for GOI’s policy of involving medical colleges in TB

control. The National Task Force (NTF) consisted of representatives from the zonal nodal centres, Zonal

Task Forces, central TB institutes, WHO-SEARO and the Central TB Division, Ministry of Health and Family Welfare (MoHFW), GOI was formed. The main role of the NTF was to guide, provide leadership and advocacy for the RNTCP, develop policies regarding medical colleges’ involvement in the RNTCP, coordinate between the Central TB Division, MoHFW, GOI, and monitor the activities of the Zonal Task Forces.The Zonal Task Forces (ZTF) facilitated the establishment of State Task Forces (STF), coordinated

between the national and State level Task Forces, as well as between medical colleges and the State/District

TB Centres, and monitored the activities of the STF. Zonal division of States for this activity comprised five

States in the East, eight each in the North-East, and the North, five in the South and five States in the West

zone. However, the real implementing unit was the STF, which undertook the necessary activities to facilitate

establishment of Directly Observed Treatment (DOT) centres, as well as other activities, in all the medical

colleges in the respective States. Over the subsequent years, wider interaction with medical colleges has

occurred through a series of sensitization seminars, training of medical college faculty staff at Central TB

institutes, national and zonal level workshops. Steps for involvement of individual medical colleges included sensitizing faculty members about RNTCP services, identifying a faculty member as a“Nodal Officer” for coordinating RNTCP activities and training of staff. Other steps included formation of a “Core Committee” consisting of the heads of various departments (Box 1). Core Committees, at the level of medical colleges facilitated inter-departmental coordination for implementation of DOTS strategy.Designated Microscopy Centres (DMC) and DOT Centres were established in all government and private medical colleges and these were equipped with suitably trained additional manpower in the form of laboratory technician (LT) and TB health visitor (TBHV). The RNTCP is one of the National Disease Control Programmes being implemented under National Rural Health Mission (NRHM) of GOI. NRHM is implemented through a mechanism of Health Societies established at State and District level. These Health Societies provide necessary administrative and financial support to medical colleges as per approved policy of RNTCP for implementation of Programme activities.

In 2003, action plans for the different levels of Task Forces were formulated and in 2004, the progress was reviewed and future course of action was planned. These annual meetings of the Task Forces also provided

an important forum for consultation with the medical fraternity on issues or new initiatives being considered

by the Programme such as external quality assurance of sputum microscopy, drug resistance surveillance,

TB/HIV management and coordination, management of M/XDR-TB and DOTS plus7-15.

Recording and reporting formats at the medical colleges 

Consequent to the decision in the NTF held in November 2004, NTF 2005 had recommended that the

existing recording formats of RNTCP would be used to document the processes in the medical college. Further, the medical colleges submitted the monthly peripheral health institution (PHI) report to the concerned Tuberculosis Unit (TU)/District (Fig. 2). In addition, it was recommended that the medical colleges, States and Zones shall submit reports to the next level on a quarterly basis on separate reporting formats. These were subsequently revised during the NTF workshops held in 2006 and 2007. The quarterly reporting formats have been implemented from the first quarter of 2006 onwards. Contributions made by medical colleges in RNTCP policy formulation In addition to the Core Committee meetings, recording and reporting of data, the medical college representatives had actively taken part in the STF meetings and the respective ZTF meetings that were held annually. Further, certain faculty members from medical colleges (e.g., Chairperson STF) also participated in the NTF meeting held annually. The action plans evolved in various ZTF meetings were deliberated upon in the NTF meeting and consensus action plan was evolved for guiding the RNTCP policy. This annual activity had been a key contributor to the RNTCP and responsible for many of the revisions and reforms that have constantly featured in the evolution of the RNTCP.The NTF has been the voice of the collective opinion of academicians in medical colleges and has contributed in shaping key policy issues, such as, ensuring that teaching and training regarding RNTCP and provision of infrastructural facilities like DMC and DOT Centre at medical colleges are made mandatory by Medical Council of India (MCI); rational use of fluoroquinolone antibiotics in the treatment of respiratory tract infections; airborne infection control policy, among others. 

Operational research

The RNTCP facilitated the conduct of operational research (OR) relevant to Programme needs by providing funds. To facilitate conduct of OR, State OR committees were formed in all the States with medical colleges and Zonal OR committees were formed in all the five zones. The OR Committees sanction funding for research projects ranging from up to `100,000 (State OR Committee), `500,000 to `1,500,000 (Zonal OR Committee) and above `1,500,000 (National OR Committee). The RNTCP also instituted a consolidated

grant amount of `20,000 for postgraduate thesis conducted on OR topics relevant to the Programme needs; at least one postgraduate thesis grant per medical college per year is awarded.

HIV-TB coordination and care

The RNTCP units (DMC and DOT Centre) and the Informed Counselling and Testing Centres (ICTC) in the medical colleges have been actively involved in the HIV-TB cross-referral mechanism (Fig. 3) of the RNTCP and the National AIDS Control Organization (NACO). The medical colleges, by their involvement

with NACO, provide facilities for CD4+/CD8+ count testing and provision of anti-retroviral therapy through

anti-retroviral treatment (ART) centres for HIV-TB coinfection. 

Management of M/XDR-TB

The diagnosis and treatment monitoring by sputum smear microscopy via quality assured laboratory services are key components of the RNTCP strategy. Keeping pace with its expansion and the increased demand for quality laboratory services, the RNTCP, by facilitating the establishment of accredited Intermediate Reference Laboratories (IRLs) and DOTS-Plus sites at certain medical colleges has also contributed to capacity building forsurveillance, diagnosis and treatment of MDR-TB. As a part of this exercise, the RNTCP has facilitated establishment of infrastructure for the diagnosis of MDR-TB by providing line-probe assay, liquid culture and GeneXpert MTB/RIF in future in the IRLs at the medical colleges. Several medical colleges in the country have already obtained accreditation for their laboratories for culture and drug-susceptibility testing under RNTCP; the processing of applications of several other medical colleges in underway.

Key contributions made by medical colleges in TB control in India

The key contributions made by medical colleges in RNTCP policy formulation and programme implementation during the last decade are shown in Box 2. Status of medical college involvement

By the end of December 2010, 282 of the 307 (92%) medical colleges were involved in the RNTCP

implementation. In these medical colleges, Core committees have been formed and DMC and DOT

centres have been established under the Programme (Table I)15. Out of the 282 medical colleges involved,

244 (87%) have submitted their reports for all the quarters during the period July 2009 to June 2010.

Supervision and monitoring by the STFs

During July 2009 to June 2010, all States organized at least one STF meeting; in total there were 55 STF

meetings. There were 77 medical college visits by the STF members and 19 visits by the ZTF members15.

RNTCP advocacy activities undertaken by medical college staff The medical colleges have reported 21 publications on RNTCP in peer reviewed journals during the period July 2009 to June 2010. All States have reported participation of the medical college faculty in Television/ Radio / Newspapers to disseminate information related to RNTCP. A total of 301 Workshops/Seminars/CMEs (continuing medical education) were conducted on RNTCP in the medical colleges. The medical college faculties have also reported conducting 31 State-level CMEs/workshops on RNTCP across the country during the period15. TB-HIV collaboration in medical colleges During July 2009 to June 2010, 216 medical college reported having both ICTC and DMCs in their premises; of these, 205 have established standard cross referrals between ICTC and DMCs. One hundred and forty two medical colleges also have ART centers and at all these centres, mechanisms to refer HIV co-infected patients to RNTCP for diagnosis and treatment of TB have been established15. Operational research activities undertaken by medical colleges

All the five zones have formed zonal OR Committees, and all the states with medical colleges have the state

OR Committees. In 2011, 72 thesis proposals and 14 OR proposals were approved by various Zonal OR

Committees1. All the State OR Committees have met atleast once during the period July 2009 to June 2010.

The State OR Committees have forwarded 41 OR proposals to the Zonal OR Committee for funding. Of

these, 31 proposals have been approved for funding by the Zonal OR Committee.The State OR Committees

approved 70 postgraduate thesis proposals for funding from RNTCP. Large multicentric OR studies on efficacy

Microscopy activities at the medical colleges

During the period July 2009 to June 2010, 92,071 of the 6,11,683 patients (15%) who had undergone

sputum smear examination for diagnosis at the DMCs in the medical colleges were diagnosed to have smear-positive pulmonary TB. Of these, 18,452 (20%) patients were started on DOTS from the DOT Centres in the medical colleges, while 65,563 (71%) were referred for treatment to the DOT centres at their place of domicile. During the same period, 45115 smear-negative patients and 81,615 patients with EP-TB were either started on DOTS from the DOT Centres in the medical colleges, or were referred for treatment to the DOT centres at their place of domicile. All the DMCs in the medical colleges have actively participated in the quality assurance protocol of the RNTCP which included on-site supervision, panel testing, and random blinded rechecking (RBRC) of routine slides. Overall, at a national level, medical colleges contributed to 25 per cent of the TB suspects referred for diagnosis, 23 per cent of new smear-positives diagnosed, 7 per cent DOT provision within medical colleges and 86 per cent treatment success rate for new smear-positive patients (Figs 4A and 4B)1,10-15.

Referral for treatment and feedback status

Of the sputum positive patients referred for treatment during the period April 2009 to March 2010 of RNTCP Category III treatment in EPTB, such as lymph node TB16, TB pleural effusions17 and Category

I treatment in abdominal TB (patient recruitment ongoing) are expected to provide valuable data on the

performance of the RNTCP DOTS regimens. 

Participation in the Joint Monitoring Mission

The RNTCP was started on a pilot basis in 1993 based on the recommendations of the first review held in 1992. The second joint programme review, conducted in February 2000, found the functioning of the Programme to be successful and had recommended rapid expansion of quality RNTCP services to cover

the entire country by 2005. The third review was conducted in September 2003 by a team of 20 national

(including faculty members from medical colleges) and 22 international TB experts. The team made field visits to five States, namely, Maharashtra, Orissa, Rajasthan, Tamil Nadu, and Uttar Pradesh18. The Joint Monitoring Mission (JMM) 2006 was jointly organized by the GOI

Early diagnosis of M/XDR-TB Early diagnosis of M/XDR-TB by facilitating establishment of infrastructure

for the diagnosis of MDR-TB by providing line-probe assay, liquid culture and GeneXpert MTB/RIF in future in the IRLs at the medical colleges. The related administrative, funding and human resource issues that are common constraints for implementing this need discussion and resolution. Institution of air-borne infection control measures Mandatory for upcoming medical colleges; modifications to be made in existing medical colleges.Fewer patients than the actual numbers diagnosed at DMC get treated under RNTCP In-depth study of referral feedback mechanism. Medical college faculty to conduct advocacy and sensitization more intensely to facilitate greater involvement of private practitioners.

Underutilization of RNTCP DOTS treatment of EPTB

For reviewing the preparatory activities for DOTSPlus, the State of Gujarat was selected. To observe TB/

HIV activities and to visit the NTI for human resource development (HRD) issues, the State of Karnataka was selected. Three other States were randomly selected from the north and east of the country (Madhya

Pradesh, West Bengal, Punjab and Haryana, being smaller States, were combined as one unit). The fourth

in the series of JMMs was organized in April 2009(20) and included representatives from all major national

(including faculty members from medical colleges)and international partners of RNTCP. The JMM team

had visited five states (Gujarat, Rajasthan, Tamil Nadu, Himachal Pradesh and Uttarakhand) and one

Union Territory (Puducherry). The fifth in the series of JMMs organized in August 2012 also included faculty members from medical colleges along with national and international partners of RNTCP. The JMM team

had visited 12 districts in six states, namely, Bihar, Maharashtra, Punjab, Karnataka, West Bengal and

Uttar Pradesh21. The key Challenges faced in the involvement of medical colleges in the RNTCP and suggested solutions are shown in Table II.

Discussion

Till the time involvement of medical colleges in the RNTCP was conceived, the interaction between the

academicians in the medical colleges and the Programme managers was sparse and on many occasions discordant. The young doctors in training seldom got an opportunity to practice what was preached to them22. As a result, the facilities available under the RNTCP were seldom utilized to the full extent possible. Keeping in mind the needs of the country, a future “5-Star” doctor who would take up the responsibilities as a care provider, decision maker, communicator, community leader, and a manager was visualized and such a future doctor would not only serve the patients and the community but would also gain their respect3. The involvement of medical colleges in TB control envisaged and successfully implemented by the RNTCP for more than a decade in India is an extraordinary effort. The Task Force mechanism has entrusted the responsibility to medical colleges to ensure their effective contribution to the efforts of GOI in TB control. The successful amalgamation of the public health approach and the expertise of academicians has immensely benefited the RNTCP and TB control in India and facilitated the emergence of the “future doctor” from among the medical students3. A model DOT Centre was established at AIIMS, New Delhi, to serve as a role model for other medical colleges in the country with the help of WHO-SEARO in September 200123,24. The initial experience gained at this model DOT centre was subsequently adopted for evolving the modus operandi for involvement of medical colleges in the implementation of the RNTCP. During 2001-2005, 1490 patients were evaluated at the DOT Centre at the AIIMS hospital, New Delhi23. Of the 768 patients with cough, 27 per cent were found to be sputum positive for acid-fast bacilli (AFB). Among patients who were initiated on DOTS, cure was achieved in 92 per cent of new sputum smear positive patients; treatment completion was achieved in 91 per cent of EPTB and 75 per cent sputum-negative pulmonary TB patients. Overall treatment success was achieved in 86 per cent24. Further , this is also reflected by the fact that, over the last decade, medical colleges have consistently contributed to nearly 25 per centm of the chest symptomatic referred for sputum smear examination and nearly 20 per cent of new sputum smear-positive patients detected annually (Fig. 4A and 4B). This reflects a significant achievement because, this large proportion of patients would have otherwise been diagnosed to have TB on radiological or other grounds and not by the reliable sputum smear examination method. These patients would also have received suboptimal non-DOTS treatment if the medical colleges were not intensely involved in the RNTCP. The robust reporting system that has been developed has provided useful surveillance data and feedback on the functioning of the Programme. Irrespective of which medical college in the country the patient is diagnosed to have TB, the referral mechanisms for treatment have facilitated the delivery of DOTS at the patient’s place of domicile.

Medical colleges, by virtue of being referral centres with more facilities for invasive procedures and histo pathological and microbiological methods of diagnosis, have enhanced diagnostic yield of EPTB, such as, TB pleural effusion, lymph node TB, abdominal TB, neurological TB, among others. These have, thus, contributed to early diagnosis of EPTB cases and facilitated institution of the standard of care i.e., DOTS

for these patients. Medical college involvement has also facilitated more active involvement of paediatricians

in the RNTCP and effective utilization of RNTCP diagnostic and therapeutic services for paediatric TB.

Some problems have been identified in the implementation of RNTCP activities in medical colleges, especially in the new medical colleges set up in the private sector. These include delay in formation of Core Committees, establishment of DMCs in some of the medical colleges. Technical doubts about efficacy of DOTS regimens particularly in EPTB cases have lingered on. Consequently, many patients with EPTB, especially, orthopaedic and neurological TB are being treated with non-DOTS treatment resulting in

inadequate utilization of the RNTCP programme. 

Constraints and challenges ahead

The inadequacies in staff and human resources, shortage at all levels requires rectification. Issues, such as, staff vacancies in medical colleges not being filled up on time, and salaries to RNTCP contractual staff not being at par with payments in the sector also need to be addressed. In some states, delay/non-release of funds to STFs has resulted in non-performance of planned activities. There is a need to ensure financing

essential for sustenance of this model. In states with a large number of medical colleges, such as Karnataka, visit by the STF Chairperson has become a practical problem. Increasing the number of STF Chairpersons

could perhaps be a solution to this problem. Poor and inadequate airborne infection control practices in most

of the medical colleges, especially the overcrowded government medical colleges has been another issue of

concern. There is an urgent need for advocacy regarding education on cough hygiene and etiquette. Weaknesses that are evident in supervision capacity and quality as well as in planning, monitoring and evaluation need to be addressed. In medical colleges, there is a need for enhanced inter-departmental sensitization and better advocacy for RNTCP and need for more contribution in pulmonary TB (smear-positive and smear-negative cases) and EPTB cases. There is also a need for strengthening the feedback for transferred out cases. This can be facilitated by holding regular core committee meetings, more intense and sustained sensitization regarding the Programme and enhanced inter-departmental cooperation. Establishment of IRLs and DOTS-Plus sites for M/XDR-TB in medical colleges would contribute to capacity building and strengthening of mycobacteriology laboratory services in the department of microbiology in medical colleges. Availability of quality assured accredited laboratories in medical colleges would facilitate better management

of drug-resistant TB and HIV-TB co-infection. Active medical college involvement in prior planning and efficient management of drug logistics cycle will avoid shortages and will ensure timely supply of drugs. However, in spite of all these deterrents and shortcomings, the landmark decision taken more than a decade ago to involve medical colleges in TB control appears to have extraordinary foresight. This has resulted in the establishment of DOTS as the standard of care for TB patients in all medical colleges and their hospitals. It is expected that through their own practice, senior faculty (professor) in medical colleges will influence the practice in the private sector as well as the future generation of physicians thus making DOTS the standard of care for TB patients in the country. This will ensure that all TB patients, irrespective of where they

seek care, receive the best available care, free of cost. Several issues need to be streamlined and improved

upon in the coming years to make this partnership between the RNTCP and the medical colleges a truly

effective collaboration. As the Programme widens the scope of services that it provides, medical colleges will have an increasingly important role to play in areas such as TB/HIV coinfection, external quality assurance of the sputum microscopy network, drug-resistance surveillance and management of multidrug-resistant TB patients. The RNTCP needs active support of medical colleges in carrying out OR in these areas to guide the development of the Programme’s future policies. Recently, medical colleges have also begun participation in airborne infection control policy implementation25. This will involve engineering works, renovation of existing

infrastructure by involving medical college authorities. Medical colleges also have the potential for evaluating the efficacy of isoniazid preventive treatment (IPT) in the field setting. Thus, by their active involvement in the “3Is”, namely, intensified case finding, (airborne) infection control policy, and IPT medical colleges are active partners in the implementation of the RNTCP. The beginning and the progress made so far seem promising. But, the need of the hour is to sustain the momentum gained and push medical college involvement forward by continuing coordination and communication. The OR relevant to the Programme needs can be further facilitated by providing attractive funding and a clear-cut modus operandi with a specified time-line so as to attract interested faculty members from medical colleges to take up research studies. Identifying thrust areas relevant to current needs of the Programme, and making available quality generic protocols can facilitate OR studies to be carried out in medical colleges in multicentre mode. There is also a need for visible networking to facilitate the widespread dissemination of the outcomes and results documented in the OR studies so that this will also enthuse and inspire more research relevant to the Programme needs. The experience from India in involving medical colleges in national Programme shows that tangible additional benefits can be obtained in TB control, especially by improving case detection. In view of this, involvement of medical colleges should be promoted widely and the experience replicated not only in theregion but also globally.

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