Public Health Perspectives in the Formulation of the National Tuberculosis Programme of India
Item
- Title
- Public Health Perspectives in the Formulation of the National Tuberculosis Programme of India
- Creator
- Debabar Banerji
- Date
- 1985
- extracted text
-
PUBLIC HEALTH PERSPECTIVES IN THE FORMULATION OF
THE NATIONAL TUBERCULOSIS PROGRAMME OF INDIA*
D. BANERJI
Professor and Chairman
Centre of Social Medicine and
Community Health
Jawaharlal Nehru University
NEW DELHI - 110 067
*A paper prepared for publication in the special
issue of NTI Bulletin.
>
Public Health Perspectives in the Formulation
of the National Tuberculosis Programme of India
INTRODUCTION
Three major steps were taken in tackling the
problem of tubeiculosis in the country, These laid
the foundation for India’s National Tuberculosis
Programme (NTP). Findings from a nation-wide tuber
culosis-prevalence survey (1) brought about basic
re-orientation of many of the then prevailing notions
concerning epidemiology of the disease. A very care
fully designed clinical trial by the Tuberculosis
Chemotherapy Centre, Madras (2) revealed that, in
clinical, epidemiological and social terms, tubercu
losis patients could be treated with antituberculosis
drugs as efficaciously at home as in a well-equipped
sanatorium. An interdisciplinary team of scholars was
brought together at the National Tuberculosis Institute 9
Bangalore (NT I) to use the findings of the national
survey and the clinical trial, and collect additional
data required to formulate a nationally applicable,
socially acceptable’and epidemiologically effective
tuberculosis programme. The NTI has also been
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successful in performing the task assigned to it.‘k9;
It adopted an approach of operational research (4) to
formulate the national programme. It also conducted
research studies to obtain crucial data from such di
verse disciplines as epidemiology, social sciences,
clinical phthisiology, microbiology, radiological
diagnosis and radiological engineering , public health
nursing and health administration.
The National,Tuberculosis Programme, which
emerged out of these efforts, turned out to be a very
potent instrument for alleviation of the suffering
caused by this disease. There has been considerable
discussion among tuberculosis workers about different
facts of the NTP and of various factors which have
hampered its effective implementation. However, many •
aspects of the NTP, which are of much wider signifi
cance to the entire discipline of community health,
have not received adequate attention from those
concerned. Some of the perspectives which appear of
considerable relevance to the practice of community
health are being presented here.
An_Er2idemio_l£gic£l_ Approach to a_Community_Health
Problem
The problem of tuberculosis has been dealt with
in its entirety as a whole in terms of its size, dis
tribution and the dynamics of the quilibrium formed by
various host, parasite and environmental considerations.
The natural history of the disease (5), worked out
on the basis of a study of the epidemilogical beha
viors of the disease, has provided a framework for .
evolving a‘strategy of intervention in the various
phases (promotive, preventive, curative and rehabili
tative) for obtaining greater impact on the problem
through the resources made available for the
programme. (6)
The problem of tuberculosis has also been
projected in a time dimension to synchronize the stra
tegy for intervention with other social, economical
and ecological forces which are likely to influence
the epidemiology of the disease over time (6), (7),(8)
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The use of the BCG vaccine as a tool for preven
tion of tuberculosis in the population is an illumi
nating instance of changes of strategy in using this
tool ir the package of intervention under changing
circumstances. In the early fifties, when the epide
miological dimensions of problems became known and
findings from Madras and Bangalore studies were not
available, BCG vaccination was considered the onlv
tool to make any worthwhile impact on the epidemiology
of the disease. (9) This consideration formed the
basis of launching the unipurpose Mass BCG Campaign
of India. However
However, with the formulation of the NTP
in the early sixties, the BCG vaccination programme
became an integral part of the package in the form
of the ^District Tuberculosis Programme . BCG vacci
nation also became part of the nationwide programme
of providing a package of immunization services to
the new born (10) Operational studies also led to
major breakthroughts ir the logistics of providing
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the services. The costly process of prior tuberc1. _
testing only to those who were below twenty years of
age.(11) Finally, on the basis of an extensive BCG
preventive trial, which can be considered as a land
mark in the field of experimental epidemilogy, date
were adduced to question the epidemiological validity of
carrying out BCG inoculation amongst adults, atleast
in India. (12)
Social Science Dimensions of a Community Health
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This has been the most outstanding among impor
tant community health perspectives which emerged in
the course of formulation of the NTP. Going to the
people in a community and learning from them what they
felt about the problems of tuberculosis has provided
insights which brought about most radical changes in
dealing with tuberculosis as a community health problem.
(13) By identifying the area where the 3felt-needsJ
of tuberculosis patients for the services overlaps
with epidemiologically defined needs, it has been
possible to develop an entirely new strategy which
gives primacy to the meeting of the felt needs among* *
tuberculosis was defined as’ a problem of suffering.
A.s, by implication, the suffering caused by this
disease is a component of the suffering caused by all
health problems within a community as a whole, a
programme for alleviation of the suffering caused by
tuberculosis has to be an integral component of the
bigger package dealing with all other community health
problems. Indeed, the tuberculosis patients themselves
showed the way to integration of services as they
sought help more often from institutions for general
health services than from specialised tuberculosis
institutions.
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The very process* of meeting felt needs of tuber
culosis cases in a community generates greater felt
needs among them, thus further extending the area .
of overlap. If, however, generation of new felt needs
falls short of the capacity of the programme to offer
services, one can be justified in taking active steps
to generate more felt need by launching carefully
designed health education drives. It has fes also been
possible to conclude from an analysis of the data on
the social science dimensions of epidemiology of tuber
culosis that a felt need-oriented NTP has a poten
tial of encompassing over 95 percent of all the cases
within a community. (14) It thus has a potentially
greater epidemiological impact on the problem than the
conventional and more expensive method of mass case
finding and treatment with the help of mass radiography.
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At the operational level, data on behaviour of
tuberculosis patients in a community were used to
devise a method of diagnozing tuberculosis patients in
rural areas which was both very simple and sciantifically very sound. Those data were also of help in
working out the details oforganizing treatment of the
diagnozed patients* Subsequent social studies of what
is termed as '’treatment default" (15), (16) had opened
up newer facets of this problem which birherto had not
received adequate attention from programme administr; '
ators and health educators.
Integration of NTP with Genera1 Hea1th Services
As pointed out above, consideration of tuberculosis
as aproblem of suffering and patient's recourse to
general health services provided the underlying logic
for integration of NTP with general health services.
There is, in addition, sound administrative justifica
tion for dealing with all the health problems of a
community as an integrated whole, demanding an integra
ted approach. (17), (18). The NTP was made to sink or
sail with general health services. As a result, if the
latter are inadequate, NTP also suffers from the same
in a equacies. The solution thus does not lie in
attempting to remove inadequacies in NTP alone but
rather in the entire health services system. Speci
alised mass campaigns or vertical programmes against
specific diseases tenc to weaken general health
services by diverting disproportionately large quant
ities of scarce health resources to these programme.
Most often these specialised programmes are not (even
relatively) cost effectiv And also suffer from the
same maladies which are the causes of inadequacies in
general health services;
NTP has thus been a pace setter in integration of
programmes for specific diseases within general health
services. Indeed, after not so successful experiences
with specialised "vertical" programmes against speci
fic conditions, such as malaria, smallpox, rapid
population growth, cholera and blindness the union
ministry of health had: endorsed the philosophy of
integrating specialised programmes with general health
services by launching the "Multipurpose Workers’ Scheme
(H9). Because of its very design, this scheme reinfor
ced the basic postulate of the NTP, namely strength'ing the general health services, Because of the
same considerations, NTP found itself in harmony with
the decision of the union government to entrust
"Peoples' Health in Peoples1 Hands" by launching the
"Community Health Workers' Scheme". (20) This
approach received further impetus from the Alma-Ata
Declaration (21) and from the launching of a progra
mme for providing "Health For All-2000 A.D." (22)
NTP can thus claim to be a forerunner of the philo
sophy of primary health care.
2eyel°Pm£ni
sation_of Services'
Sy<stem__Throu£h_Re.gionali-
The most outstanding feature of the NTP is
that in this programme a specific effort has been
made to subordinate technology .to the people, rather
than the other way found. By analysing the then
available technology or by generating specific
technology, the programme formulators took special
care to ensure that technology used in the programme
emerged from a consideration of: (a) limitations
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of the resources; (b) knowledge about cultural
meaning and cultural perception of the problem; and
(c) the health behaviour that is generated by the
cultural factors and access of people to technology.
Because of this people-oriented approach to techno
logy? they were able to withstand pressures for
inclusion of the then emerging advances in this
field, such as tomography,mass radiography, advanced
thoracic surgical techniques and expensive second
line drugs.
Based on data on the cultural, social, economic
and epidemiological situation in the country, diagno
sis of tuberculosis patients through examination of x.
sputum smears from the symptom°tics and their
treatment at home with not very expensive combination
of anti-tuberculosis drugs, formed the sheet anchor
of the NTP. This led to considerable decrease in
dependence of people on professionals and on sophisti
cated, imported equipment, apart from drastically
reducing the cost. (2?) However, the more elaborate
services thit are available at higher levels were
also mobilized as referral agencies to support work
at the periphery. Thrugh the bulk of the patients
could be treated efficiently at the periphery, those
needing more sophisticated diagnostic techniques or
special treatment regiments were referred to the
District Tuberculosis Centre (DTC). The DTC, in turn
can count on support of even more sophisticated
services available at the State Tuberculosis Centre
Qr super-specialities available at teaching hospitals 9
■fco deal with the very small fraction of cases which
did require such interventions. As all these specia
lized
agencies formed an integral component of the
NTP, they too hvve reverse referral linkages with
the periphery. Thus, while avoiding unnecessary
professionalization .and mystification, the NTP also
includes sophisticated techology in a measured way.
A
.
Information System^
There are two notable features of the health
information system of the NTP: the postulates of the
NTP provided a framework' of identifying the pieces
of information to be collected; and the details of
information system were worked out on the basis of the
capacity of the programme organization to generate,
transmit and process the information. The information
system was used for monitoring, evaluating and taking
the indicated corrective actions.
-There are three major components of the informa
tion system. One relates mainly to data on administ
rative and operational aspects of the NTP in a given
population. The second to the actual process of
implementation of the NTP, for example, preparing
index cards, monitoring of treatment and keeping
track of the cases that are transferred from one instituion to another. The third component relates to
epidemiological analyses of the impact of the NTP on
the problem of tuberculosis within a population.
Team Training for Implementing a Community Health
Programme
.
A~^eam approach to training of personnel of a BTC
. another distinguishing feature of the NTP. A team
for a DTC is lead by a District Tuberculosis Officer
'■•nd. it consists of a treatment organizer, a radiologist,
a laboratory technician, a BCG Team Leader and a stati
stician. NT I has formulated a very effective programme
.... 5....
... 5 ...
for training of a DTC team (24) . Broadly, it consi
sts of exposing the entire team to the general philo
sophy underlying the NTI in such a way that it could
be understand by every member of the team. This
enables individual members of the team to identify
what his/her role is and how his/her workcontributes
to the programme as a whole. This is followed by
training of individual members in their own specific
fields where emphasis is laid ;n aspects particularly
relevant to the NTP. Finally, each DTC team is
reassembled and the team is trained to work as a DTC
team under actual field conditions, they are likely
to face on heir return to their posts.
Use, 2t_0pera.ti.onal Re£e:arch_Methodology_for_Solving_
a_ Oommun ity Health_Probl£m_
The most significant aspect of this approach
Was that it was evolved in NTI in the course of
attempts to solve the problem assigned to it. The
starting point was not operational research as
enunciated by experts in this field; (25) the star
ting point was the problem and it turned out that the
approach of operational research provided a very
valuable framework for finding a suitable solution
to the problem. (4)? (26) It was realized quite early
that solution of the problem required consideration
of a large number of variables which pertain to a
number of disciplines and which are in complex inter
raction with one another. Fxr this purposes
1. The problems of tuberculosis in India are
elaborately defined, both in conventional epidemiolo
gical terms as well at in social terms (as a problem
of suffering or as a felt need)
2„ The factors that are relevant for finding a
solution to the problem were identified and special
studies were conducted to obtain data concerning
those factors for which data were not already
available,
An attempt was then made to put these
factors together in the form of a model (not nece
ssarily ’’mathematical;’) to depict the major intera
ctions amongst them and work out alternative ways
of solving the problem through alternative ways of
influencing different components of the model within
the constraints of the available resources.
4. The model was then used to make forecasts
concerning outcome of the alternative ways of
problem solution in order to choose the ond which
offers most effective use of the available
resources
5a The chosen alternative (solution) was then
put to practical test (teat run) under real^l^ife
conditions (as opposed to condition of a pilot
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study) to test the validity of the assumptions that
had been •made in choosing the solution.
6. The findings of the test run were fed into the
chosen solution and the letter was then put into normal
operation. A feedback system, which was built into
the programme, ensured continued monitoring of the
implementation.
It thus so happened that this approach was the
one that is followed in operational research, This
experience of programme formulation can also be used
for formulating other health programmes - eg.
programmes to deal with specific health problems, such
as malaria, leprosy, maternal and child health or
family planning or programmes for improving working
of health organizations such as ho.spitals, rural
health centres and the Community Health Volunteers’
Scheme .
2^£v_iding Institutional Framework for Solving a
Community Hea^lth^Probl.em^
The three institutions, namely the Indian Council
of Medical Research, conducting a nationwide prevelance
survey of tuberculosis, the specially established
Tuberculosis Chemetherapy Centre carrying out to be a
historic clinical trial in the field of community
health and the National Tuberculosis Institute
performing the pivotal role of formulating the NTP
(and following it up to provide training, research and
consultation support to the NTP), have made crucial
contributions in dealing with tuberculosis as a
community health problem in India. This underlines
the need for developing similar institutional frame
works for dealing with other pressing community
health problems (such as malaria, nutrition? maternal
and child health, leprosy, filariasis, blindness and
family planning).
Conclusion
Formulation of a nationally applicable, socially
acceptable and epidemiologically effective national
Tuberculosis Programme for India involved use of a wide
range of principles of the discipline of community
health. These principles can also be very profitably
applied in the formulation of nationwide programmes to
deal with other major community problems. Government
commitment to strengthening rural health services in
India by using multipurpose health workers and by
employing community health volunteers has further
strengthened the case for adopting the approach deve
loped for formulating the NTP on a much wider scale.
This approach also gets further endorsement from the
concept of Primary Health Care contained in the AlmaAta Declaration. Indeed, the approach to formulation
of NTP, developed in the early sixties, had antici
pated the approach that is now being advocated world
over for attaining the goal of Health For All by
2000 A.D.
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