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WHY INTEGRATED TUBERCULOSIS PROGRAMMES HAVE NOT SUCCEEDED
AS PER EXPECTATIONS IN MANY DEVELOPING COUNTRIES—A
COLLECTION OF OBSERVATIONS12

D.R. Nagpaul’
Summary : Hard work is still needed io nuke integrated tuberculosis services, and1 integration
in general, acceptable to health workers and to Improve al! the support systems for integrated
tuberculosis services to the extent that the envisioned fruits are borne simultaneously with the
introduction of these services through primary health care.

Now that case-finding and treatment for
tuberculosis are being considered for intro­
duction into primary health care, it is relevant
that the experience gained from integration of
vertical tuberculosis programmes into the
general health service be reviewed critically.
It would be unwise to let the problems and
weaknesses of integrated national tuberculosis
programmes (NTP) flow into the new emerging
primary health care system without batting an
eyelash.
It could be stated at the outset, and with due
emphasis, that there really is no alternative
to an integrated tuberculosis service, all its
drawbacks notwithstanding. The point at issue
is that the present form of integrated TNPs
need not necessarily be the basis of application
of—tuberculosis control technology through
primary health care.

and proper vaccination technique were neg­
lected by general health workers to the extent
that some special programme aspects had to
be reintroduced under the Expanded Programme
on Immunization to make BCG meaningful.
In some countries even voluntary/private
agencies have joined hands with the govern­
ment’s integrated NTP but specialized insti­
tutions, both under public and private sectors,
still maintain that they purvey a much superior
kind of tuberculosis service compared with what
general health institutions have to offer. A
degree of competition exists between general
and specialized health institutions in securing
preferential attention of the public, despite
free-flowing bilateral referral provided under
the NTP. This should be enough to confuse
the health workers and the public alike.

Integration is great to talk about

Success with integration has been patchy so far

In the 1960s, when WHO started recommend­
ing NTPs, especially for developing countries,
the epidemiological, socio-economic and opera­
tional reasons in its favour were indeed compel­
ling (W.H.O. 1964, 1976). After over two
decades, it cannot be truthfully said that NTPs
have succeeded; nor that they have failed. The
old justifications have not changed since, but
the manner in which integration was brought
about Has provided a fresh perspective.
It is true that a tuberculosis patient out in a
village has a much greater chance today than
before of being diagnosed and treated, but the
proportion being missed, misdiagnosed and
improperly treated is uncomfortably large.
And. it appears, nothing much is being done by
the integrated health services to correct the
situation. True again, that a newborn baby,
infant, or school" entrant has a far greater
probability of getting BCG vaccinated under
the integrated health services, compared with
the BCG mass campaign days. But, vital aspects
like maintaining the potency of the vaccine

Health officials and workers often talk
about integration knowingly and with en­
thusiasm but, like the talk about weather,
nobody docs anything about it. The number
who “know” what is wrong with integration is
legion. But it is not for them to find out the
reason thereof and do something, albeit at
their own levels.

Compartmentalized thinking, attitudes, and
functioning abound at all the levels of the health
infrastructure. Strangely enough, those present­
ly charged with primary health care do not
appear to be above all this. To many, it is the
newest health technology and those not directly
involved could be kept at arm’s length. Is
primary health care gradually and uncon­
sciously being regarded as a new speciality?
Philosophy of integration is understood but not
really accepted
Integration is most visible in the grassroots
level rural health institutions because that
is where in the estimation of most health

1Also issued as WHO/IUAT/JSG/BP/81 4 document.
2WH0 Medical Officer, WPRO, and formerly Director, National Tuberculosis Institute, Bangalore, India.
N.B. Views expressed in this article arc the author’s own views-Editor.

Ind. J. Tub., Vol. XXIX, No. 3

150

D.R. NAGPAtt

officials, integration is most suited and needed.
in cities and higher levels of the health organi­
zation, integration is cither missing or cosmetic,
because it is regarded as unnecessary there.
Despite the welcome success of integration in
.rural health institutions the attitudes and
Vpractices of rural health staff are notalways
' helpful. Poor attitudes could be the reason for
the sizeable misdiagnosis and mistreatment in
respect orTubcrculosts under" the" integrated
health service. By training and the examples of
peers, health workers face serious problems in
forming the needed attitude towards integra­
tion. Besides, integration conceptually is "not
meant for rural areas alone. Attitudinal and
functional changes have to take place at all
levels of the health infrastructure, for success
even for the most peripheral level (W.H.O.
1965 and D.G.H.S. 1967).
The widespread covert non-acceptance of
- integration at all levels is there, perhaps, because
integration cuts across the present-day medical
sociology and health services politics. The
, apprehensions, insecurity, and_c_onfusion gene­
rated by integration among health workers arc
just too many. The absence of a strong logical
support to the fears is what is making the nonacceptance covert and non-vocal.

Highly placed-officials,-who.-often exercise
disproportionately large influence on account
of expert clinical services rendered by them to
those in political, power, are'the ones espousing
the idea that integration needs to be confined
only to the rural health institutions; that people
need and are demanding the establishment of
many more specialized and prestigious centres
and that no country can afford to lower its
medical expertise and not have at least a few
centres equal to the best in the world. In this
way they try to meet the “threat” posed by
integration to their "positions prestige acquired
through' a different system. The element of
truth in their statements conveniently is not put
in the perspective that could often be achieved
only by denying the simplest health services or
rendering second-class services to the millions
to provide what is first-class to a few. It is done
perhaps because it is a question of survival for
them.
The purpose of the above suggestion is not
to denigrate but_to ascribe the often noted
“weak” political will behind many a public
health programme, the re-separation after the
passage of some years of departments, bureaux,
posts and functions that had been integrated
earlier, the continued opening of new tuber­
culosis hospitals and centres when their non­
essentiality has been amply demonstrated, etc.

Ind. J. Tub., Vol. XXIX, No. 3

to just one causation, namely, noh-accepfancc
of integration. None can afford to be overly
critical or cynical. It is those, who arc either
pushing forward integrated health services,
primary health care, etc. or have to sit in judg­
ment over their success, that must search their
minds. Must_planning for the better health of
the people brush" aside*the felt-needs of the
professional staff who have to carry out the
plans?
Need for acceptability studies
At the time when integration of health
services was being recommended, a pilot project
or two in every country helped to demonstrate
to the local workers that the strategy is feasible
and works well. The menial walls appeared
much later. One after another even promising
NTPs got bogged down with difficulties. The
pilot project approach is also being used to
promote primary health care, to attain the goal
of "Health for All by Year 2000”. This is good,
but when will we learn that what is feasible is
not necessarily acceptable?

Time and effort must be spared now for
acceptability studies regarding integration. No
sooner had difficulties arisen with integration
in respect of NTP than health services research
should have examined its pragmatic basis.
Pragmatically planned programmes are essen­
tially short-term expedients, but for one reason
of another they succeed in eluding scientific
scrutiny for varying periods. If this note is
regarded as overly critical or unrealistic, prag-.
matism will win once again.
This is not to suggest that nothing should
be done until the studies arc completed. There
is also no denying that a long time is needed to
bring about a major change from spccialization/high technology of the vertical programmes
involving concentration of “line” and “staff”
functions in the hands of the same persons, to
the people-oriented integrated services with
stress bn decentralization, prevention and cost­
benefit. The points being made are that a
quarter of a century has elapsed and we do
not have unlimited time at our disposal since
primary health care services have to be pushed
forward now and that we are in a stalemate
with regard to integration and do not have
sufficient awareness as well as knowledge about
what to do.

There was inadequate preparation
A part of the blame for the poor attitudes
and practices among general health workers

WflY INTEGRATED TUBERCULOSIS PROGRAMMES

Under some health programmes the
grant of in.ce.ntiyc_pay is permitted on
the grounds that health workers in
most developing countries get poor
salaries. There is no reason why health
workers should get less salary than
comparable other categories, but link- .
ing this up with the aim of achieving^
higher targets in respect of a high f
priority health programme, which in- '
disputably leads to neglect of other
activities and duties in health ihstitu- ’
tions, borders on the undesirable.
Ironically, in spite of the incentive pay
the achievements may turn out to be • I
fictitious if'supcrvision is lax or cannot ''
be exercised for a period. Primary
category training as “multipurpose
health worker”, to cover all the integ­
rated health duties as the terms of
service al entry, better salary, and.good.,
supervision may resolve lhe problem.

Other observations
Besides poor acceptability of integration,
and inadequate preparation for its imple­
mentation, there is :

unexplained, almost paralyzing, lack,
of sustained intcrest/cnlhusiasm among
general health workers in respect of
tuberculosis services; perhaps some
other programmes as well. Compared
with acute diseases and physical injuries,
the beneficial results from tuberculosis
services do not become visible quickly,
which may lead to a general state of
disinterest...But, in some cultural milieu,
the apathy tends to disappear when a
family member, friend, or a person with
a “letter of reference” approaches for
the service, suggesting that a part of
' the ' explanation is insufficient . social,
consciousness among health workers.
Therefore, the apathy needs looking,
into and not merely explained away.

(a)

(b)

Health workers are prone to regard the
functions connected with their “category
training” for entry into service as
“legitimate duty” and other duties
given to them as multipurpose workers
merely as "extra work”. This psycho­
logy of extra work perhaps is behind
persistent demand for "incentive pay”

151

when other duties arc entrusted to
them in the wake of integration, on the
grounds that they are overworked. A
number of studies has demonstrated
that all categories of health staff in ”
rural health centres, Including medical
officers, arc in fact under-utilized. Yet
the myth of overwork continues to
jhrive~a'iTcrTs generally'accepted'. No
sooner are more hands provided to
help reduce the overwork, than the
staff tend to revcrt_to the unipurpose ,
system of work, sometimes by private '
arrangements among themselves. If
supervisors would not allow it openly,—
they arc ready to turn a blind eye
towards it.

must be borne by those who had the responsi­
bility for bringing about integration. Compared
with what was demonstrated to them in pilot
projects, the preparations they made for the
extension phase were either deficient or grossly
inadequate, in order perhaps to attain the set
extension targets. Some programme extensions
comprised merely an administrative order and .
despatch of supplies. Training quite often was
improperly organized with the result that un­
trained staff rendering the services, some trained
staff awaiting equipment and supplies long
enough to forget their training,. and micro­
scopes lying around in packing cases for years,
were observed quite frequently. The seminars/
workshops that were organized for training
laid far more stress on technology , and top
little on the change of attitudes. The people in
general were hardly prepared for the integrated
services and its enshrined referral system. It is
not clear how during the pilot phase the com­
parative inadequacy of organizalional/training
capabilities, available generally to tackle the
enormous task of extension, was not foreseen
and something done about it. It is hoped that
history will not repeat itself when it comes to
extension in respect of primary health care.

(c)

One of lhe reasons for NTPs not
succccdings as per expectations could
be that the cxpectati.onsare unrcalistic.n
After all, these expectations are those '
of the overseeing specialized workers
who arc not really familiar with the
structure and dynamics of a general
health service. Replacement of population/prevalence-bascd targets wiffi
operational ones within the reach of
multipurpose health workers might
provide the answer.

(d)

The "oil . crisis" facing the world,
especially the developing countries, may
yet prove a blessing in disguise for the
integrated services. Parenthetically,
transport is an essential prerequisite
for implemcntors/supervisors of a public
health programme. The role of transport

Ind. J. Tub., Vol. XXIX, No. 3

1<2

b.R.

nagpaul

as an image builder of health workers, vision, and the general climate of confusion and
however, became apparent when at­ apathy. No cut-and-dried solutions for the
tempts were made to apply management interregnum are offered on purpose, not because
principles leading to the optimal use it is not possible to offer some suggestions. The
of all roadworthy vehicles belonging temptation has been resisted. If the earlier
to any health programme in an area. pragmatism and successful pilot" projects"did
Marked reluctance was observed for not quite succeed, more time should not be
programme functionaries to travel by lost in trying some new pragmatic solutions,
public transport
when necessary, thus tinkering ,with the problems instead of
share the vehicle with others from tackling them systematically.
sister health programmes, and agree •
to the allocation of roadworthy trans­ Tuberculosis control technology and philosophy
port according to optimal utilization of primary health care
and not merely status of those using
However, there is one basic point between
them. The most frequent reaction to
“pooling of vehicles” practice was for NTPs and the primary health care systems that’
needs
a pragmatic rationalization now. Under
the supervisors to forego supervision
duty on one plea or another. Now, the philosophy of primary health care, people
have
the
right and duty individually arid col­
with increasing problems of main­
tenance of vehicles and rising price of lectively to participate in the., planning and
gasoline, coupled with insufficient implementation of their health care activities.
budgets for supervisory' travel, a pat­ It "has to be remembered, however, that at
tern of small radius supervision ex­ times people’s perception of the health “threats”
ercised fro'nt-each successive level in a facing them and their participation in meeting
step-ladder fashion might help resolve the hazards has to be moulded through health
education. Tuberculosis and leprosy have a
the problem.
long history 'of “stigma” which even today
(e) The supervision of NTPs by general makes individuals and families deny that the
health workers has been decidedly hazard exists for them. They may agree to
infrequent, and at times even incorrect, these diseases being a community problem, to
making it altogether grossly insufficient. which they may accord a low priority. True,
Quite often, there is great enthusiasm comparatively fewer persons in the community
at the time of introduction of integrated are afflicted with tuberculosis, but those few
tuberculosis services in a health centre, suffer a lot more than others having most other
but very soon hardly any case-finding diseases (Nagpaul ct al, 1966). And, before
or treatment arc" left to be seen, as if dying, they infect healthy contacts—about ten
the service had never been introduced in the case of tuberculosis—who may develop
at all. The specialized “staff” officers the disease much later. There has to be a kind
in the higher levels often try to correct of understanding, at this stage, on the point of
the situation by exercising supervision educating the public suitably, because faced
at all levels, which is obviously an with the enormous and difficult task of ushering
impracticable proposition, if proper primary health care in the context of a low
supervision of integrated tuberculosis' perception of tuberculosis as a health hazard,
se¥vices‘t>y the general health service whatever gains NTPs have already registered,
“line” officers cannot be expected at may be allowed to wither away. That would
present, it would take a long time to mean a real failure of integration.
make tuberculosis services meaningful
under primary health care
REFERENCES

Not by studies alone
An impression might have been given that
nothing could be done to correct the present
not so satisfactory position of NTPs until the
operational studies have been completed. That
technology of tuberculosis control has reached
the peripheral level is a gain which should not
be thrown to the winds while awaiting scientific
studies. Until then, the status quo should
continue with whatever could be done to
improve poor attitudes, weak programme sup­
port systems, inadequate training and super­

Ind. J. Tub., Vol. XXIX, No. 3

1.

2.

3.

4.

5.

Directorate General of Health Services, Govern­
ment of India, New Delhi; Committee on Integra­
tion of Health Services. Report; 1967.
Nagpaul, D.R. ct al; Suffering in tuberculosis :
Proceedings of Tuberculosis and Chest Diseases
Workers Conference, Hyderabad, India; 1966.
WHO Expert Committee on Tuberculosis. Eighth
Report; Tech. Rep. Ser. 290. 1964;
WHO Study Group on Integration of Mass
Campaigns against Specific Diseases into General
Health Services. Report; Tech. Rep. Ser. 294; 1965.
WHO Expert Committee on Tuberculosis. Ninth
Report; Tech. Rep. Ser. 552; 1976.

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