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Ind. J. Tub.J993. 40, 129
Origin*11 Article
fvaluation of performance of national tuberculosis
evalua ion programme during VI1 plan*
V.V. Krishna Murthy1
I
7?
. T r jj
-df *
f
'
1^'^
■L, b ’• t '•
■In
various States received at lite National Tuber
culosis Institute, Bangalore and some publica
tions of the Ministry of Health & Family Wel
fare were used for this evaluation. A budget
of Rs. 600 million was allocated to the N 11
fur the VII Plan. The analysis revealed a sub
stantial increase in the number of sputum ex
aminations and new cases diagnosed com
pared with the VI Plan period; the numberor
cases diagnosed, however, was not commensu
rate with the number of examinations per
formed; contribution of PHIs to case-finding
activity had increased; an improvement was
observed in the pattern of drug collection by
patients on standard chemotherapy regimen
and in programme efficiency; compared with
quarterly reports the submission of annual
reports was not satisfactory. Actual expendi• ture on NTP during the VII Plan was Rs. 1174
million (excluding over-head costs). I he esti
mated cost of diagnosis of a sputum positive
case in Peripheral Health Institutions was
Rs. 33.10 and at District Tuberculosis Centre
Rs. 90.00.
Introduction
The National Tuberculosis Programme (NTP)
was launched in the year 1962. During 1975, on
behalf of the Ministry of Health & Family Wel
fare, an expert committee constituted by die In
dian Council of Medical Research (ICMR) re
viewed the aims, objectives, implementation and
performance of die NTP dirough analysis of peri
odic reports and field visits. The committee found
die conceptual and structural foundations of die
-programme to be basically sound and recom•
mended a number of measures for improving its
■
operational effectiveness.
■
A team of experts of the Swedish International
|
Development Agency (SIDA) evaluated the NTP
|
during 1979, and again followed it up in 1985.
■
In°tlie year 1988, die Institute of CommunicaI
lions, Operation Research & Community Involve|
ment, Bangalore, an independent agency, confl
ducted an in-depth evaluadon of NTP and made
|
several recommendations.
|
NTP was included in the 20 Point Programme
<
of die Government during the year 1983.
Since die VII Five Year Plan has just con
cluded, a desk evaluation of die performance of*
NTP for die said period is attempted. The per- .jvj
formance in respect of implementation?case-findin<», treatment, reporung, and the cost aspect of
die programme acuviues has been evaluated and,
wherever possible, compared with die perform
ance during die VI Plan.
The NTP is about 30 years old and its concept
as well as outline of die activities have been docu
mented in considerable detail1 . In brief, the op^
erational objectives are to detect tuberculosis
cases from die out-patients of die general health
institutions and treat them. Sputum and X-ray ex
aminations are die diagnostic tools and duration of
treatment is eidier 12-18 mondis (Standard Regi
men - SR) or 6/8 months (Short Course Chemo
therapy - SCC).
The basic organisational unit of NTP is the Dis
trict Tuberculosis Programme (DTP) which con
sists of a District Tuberculosis Centre (DTC) usu
ally situated at die district headquarters and Pe
ripheral Health Institutions (PHI), mostly Primary
Health Centres (PHC), located in rural areas. Tu
berculosis case-finding and treatment acuvides
are integrated with General Health Services
(GHS).
Paper presented at 47tll National Conference on Tuberculosis and Chest Diseases, Bombay : 26th to 28lh
November, 1992
1. Statistical
Assistant,
Corre^ndenee.
DirccTc^
B^'—560 003
EVALUAIION OF PERFORMANCE OF NTP
V.V. KRISHNA MURTHY
131
130
Table 1 Government health expenditure
Industrialized
countries
World
12.28
10.38
in relation to total expenditure in different countries in 1985*
Table 3 Implementation of DTPs during VI & VII Plan periods
Year
Developing countries
Africa
Asia
India
7.93
3.14
2.16
Pakistan
Sri Lanka
1.00
3.77
•Source : Health Information India - 1989
ft
(2.16%) w'as one quarter of dial in African coun
tries (7.93%) and one sixdi of that in industrial
Method
quarterly and annual reports tire also received at
die National Tuberculosis Institute.
The quarterly and annual reports of NTP re
ceived from various Slates, for the 10 years of die
VI and VII Plans (1980-85) & (1985-1990), at die
National Tuberculosis Institute (NTI), Bangalore
and various publications of die Ministry of Healdi
& Family Welfare, viz., Healdi Information India,
Performance Budget etc., have been used in diis
For the VII Five Year Plan, Rs. 600 million
was allocated to NTP. A comparison of die pro
portions of health budget allocated to die three
contemporary national health programmes and die
Budget allocations
The total financial outlay of die Vll Five Year
Plan (1985-90) was Rs. 1,800.000 million. The
-health services”
were
allocated 3.7%
Programme Implementation
ods, is given in Table 3.
Table 2
Family
welfare
1
2
3
Budget allocation (%)
1.8
1.9
Per capita expenditure (Rs.)
1985- 86
1986- 87
6.30
7.19
:
:
Total plan outlay
Budget allocations
■
7.63
8.22
Leprosy
Tuberculosis
4
5
6
/
12.6
2.4
"H.’S
1.12
0.18
0.15
1.01
0.18
0.15
Rs. 1,800.000 million
Cols. 2 & 3 : % to plan outlay
Cols. 4 - 6 : % to Col. 3
76
87
22.333
25.000
10.240
12.810
86
21.300
15.270
420
420
1990
438
378
Percent
46
51
54.
___
; ... •
....
m die VII Plan. At d>e end of die VII Plan. 86% of
>fl/
die urban community and 54% of die rural com-//
i-//
rise-finding
cpse-finding and treatment activities of fTI P. The
targets
targetsfixed
fixedfor die VII Five Year Plan period and
munity were provided widi die tuberculosisserv----ices under NTP.
1
' achievements
''
■ i related
are shown in Table 4.
A target of 17 million sputum examinations to
be done in PHCs was fixed and 11.65 million spu
tum examinations were performed, reaching 68%
of die target. Similarly, a target of 1.4 million new’
cases was fixed for die first year of the Vll Plan
(1985-86) and gradually increased to 1.6 million
annual reports are received at die NIT for moni
toring purpose. During 1990,167c of die expected
quarterly reports were received at NTI, a majority
of which were considered satisfactory for monitor
ing analysis. Hence, die reporting efficiency was
73%. However. onl^27% of die expected number
of annual reports were received of which only
2/3rds were wordiy of further consideration, re
ducing die reporting efficiency to 17%. It is to be
Implementation of NTP in various districts has
been a continuous process since 1962. The prog
ress in diis regard, over die VI and VII plan peri
Malaria
320 t
1980
1985
The NTP activities are reported monthly to the
District and Slate levels, quarterly and annually to
Slate and National levels. Copies of quarterly and
Budget allocation for various health schemes and per capita expenditure during VII Plan
Health
care
Implemented
Pills
Reporting
gramme was die least of die diree programmes.
(Rs. 67,000 million) of die plan outlay, as com
pared to about 3% in die previous six five year
plans. The percentages of government health ex
penditure to total expenditure in different coun
tries in 1985 is given in Table 1. The percentage
of health expenditure to total expenditure in India
No. of
rural health
institutions
During flic VII Plan, SCC was introduced
(1986-87), in a phased manner. At the end of VII
Plan, about 50% of the districts in lite country
were providing SCC. though not uniformly.
per capita expenditure (under plan) on various
health services, is given in lable 2.
It is seen from Table 2 dial die allocation of
1.7% of die healdi budget for tuberculosis pro
Findings and Inferences
Percent
.■C,-
health programmes like National TB Programme,
National Malaria Eradication Programme, Na
tional Leprosy Eradication Programme etc., and
die general health care services (Rs. 34,000 mil-
evaluation.
No. of
DTPs
At die beginning of die VI Plan (1980), NTP
Targets and Achievements During the VII Five
had been implemented in 76% of the districts and
Year Plan
46% of the rural healdi institutions in die country.
During die VI Plan, NTP was implemented in 44
Since inclusion of NTP in the 20 Point Pro
more districts and 2,570 rural healdi institutions
gramme during 1983. die Mii»stry of Health and
(RIH) as compared to 14 districts and 2.460 Kills * Family Welfare ha^e^fix^atmual'^sZ
ized countries (12.28%).
The budget allocated to health services in India
was shared almost equally by die Family Welfare
(Rs 33.000 million) programme, various national
Periodicity of reporting under NTP is
monthly, quarterly and annually, of which die
No. of
districts
mentioned here dial in die annual report, result of
cohort analysis is made available in addition to die
case-finding activity which occurs also in die
quarterly report. 1 he efficiency of die quarterly
report being 73%, die low efficiency of die annual
report is due to die unsatisfactory reporting of
treatment activity which in turn depends on the re
ceipt of treatment cards from PHIs and correctness
and legibility of die entries on treatment cards.
The rectification of diese weaknesses may im
.
.
- ----- , -
prove die efficiency of die annual report.
Table 4 Targets and achievements ofNTP during VII
Plan period
Activity
Target
Achievement
(%)
Examination of sputum
(million)
17.0
68
Detection of new tubercu
losis cases (million)
7.45
102
Percentage of cases detected
to total estimated cases
40
35-39
Percentage of disease arrested
cases out of those detected
65
Not available
Sources :
Performance Budget. Ministry of Health &
F.W. and Health Information India
for die fifdi year (1989-90) - amounting to an in
crease of 14% corresponding to die budget in-^
crease of 9% (not on I able). I lowever, Tbr die eti-
tire VII Plan, the target for die detection of new
tuberculosis cases was 7.45 million against which
a total of 7.6 million cases was reached, attaining
EVALUATION OF PERFORMANCE OF NIP
V.V. KRISHNA MURTHY
133
132
T.bl. s
100
V’ v”^" ’’‘ff
Increase
During Plan
Aclivity/lnstitution
VI
71
70
Id
VH
(million)
50
13.5
29
89
20
147
X-ray Examinations
OTP
10.5
Sputum Examinations
DTP
DTC
PHI
11.0
5.0
6.0
Sputum positive
cases
DTP
DTC
PHI
1.1
0.6
0.5
20.8
6.0
14.8
1.5^
0.7
0.7
3.2
4.8 >
Sputum negative cases
Contribution of PHIs (%)
Sputum examinations
Sputum cases
I
54
71
41
50
22
A
9
.
40% which was more or less achieved.
Case-finding activity
„,mposit.ve cases and 4.8 million sputum nega
te cases were d.agnoxd. showing
‘ncrease of
32% and 50% respectively over die V 1 Plan pe
riod PHIs had diagnosed 62% more sputum posilive cases in the VII Plar ; riod over die VI Plan
as compared to 117. in DTCs. indicating that the
case-finding activ.ty in DTCs might have almost
Diagnostic examinations
reached die optimum efficiency.
During die VII Plan, a total of 17 million X-ray
examinations and 24 million sputum examinations
were done (not shown on Table) Of these. 79% of
X-ray examinations and 87% of sputum examma
tions were done for die new out-patients at the
DTC and PHIs. In respect of newJGra^andjpu-
tum examinations, done during VII Plan, an increase of 29% and 89% respectively v»as observe
over die VI Plan period (Table 5). The increase
observed in die number of sputum examinations
was mostly contributed by the Pl Ils (»47%L
During die first year of die VI Plan (1980-81).
PHIsliad done0.54 inillionnamputumexamina
tions which increased by 307-/, (to 2.2 milliyn)
during die fifth year of the plan, compared to an
increase of 11% m DTCs (not shown on the
Table) The increase in the output of Pl Ils may be
due to die inclusion of NTP in the 20 Point Pro
gramme in 1983. However, the corresponding in
creases during the VII Plan were lOTI and 14'X re
spectively.
Contribution of PHIs in case-finding
During die VI Plampenod. 54% of total sputum
examinations and (41%) of the total cases diag
nosed were contribut'd by PHIs as compared o
71% and 50% respectively during Uie-VH Plan_Vperiod (Table 5). Considering dial PHh die ex
pected to contribute around 80% to die case-find
ing activity. 71% contribution in sputum examina
tions and 50% in die total cases found is encourag-
gThe trend in die contribution of PHIs in yearly
case-finding activities in relation to die total per
formance over die decade is shown in F.g. • The
increased contribution from PHIs during the VI
Plan period was conspicuous but marginal during
die VII Plan period.
During die VII Plan period. 1.45 million spu- .
of examinations done.
For comparison, the case rates among
putum examinations done in PHIs and DTCs at
e end of V, VI & VII Plan are shown The case
les, in PHIs at die end of die VI Plan (5.2%) and
II Plan (5.1%) periods were one half of dial at
: end of the V Plan period (11.1%). The above
nation was marginal in DTCs (12.7% to
.4%).
During 1980, die average number of sputum
aminations done in PHIs was 1700, and the case
e 11 1%. During 1985, the average number of
aminations had increased fourfold (69(X)) and1*:
case rate reduced to one half (5.2%) and the
ne trend, of decrease in die case rate with inase in die number of examinations, continued
mg 1985-90. May be. with die increase in
l num examinations, die quality of selection
fc sputum examination got diluted to a great
e ent Consequently, the number of cases
u gnosed was not commensurate widi die number
Chest Symptoinatics attending PHIs under-going
sputum examination
In NTP, chest symptoinatics (CS) attending
PHIs are eligible for sputum examination. It is
expected that consequent to the increase in spu
tum examinations tlic proportion of CS attending
PHIs and sputum examined would increase. The
numbers of CS in rural community and of lliem.
those attending PHIs (11.1% and 24.1%
respectively - Radha Narayan et al:) were esti
mated for the years 1980, 1985 and 1990. The
number of CS attending PHIs and of them those
sputum examined are shown in Table 7.
During 1980, 10% of the CS attending PHIs
were examined by sputum; this proportion in
creased to 47% during 1990. Despite this five fold
Table 7 Proportion of chest syinplouuilics attending
PHIs who were sputum examined
bit 6 Comparison of positivity rates according Io
institution doing sputum examination dur
ing successive Plan periods
The question whether the number of cases di
fill
|>TC
WP
1990
Fig. 1 Percent contribution of PHh in case-finding (1^80-1990)
CS attending Sputum
Pills
examined
in Pills
(estimated)
(millions)
Year
Al the end of Plan
Sputum positivity rate at different limes
would reflect the quality of sputum examinaugm.
1985
SP. Exam = Sputa examined, SP. Patients = Sputum positive patients
IIUt>< ill
agnosed remained commensurate with the sputum
examinations done is examined in Table 6 since it
Sputum positive cases
-
VII Plan
VI Plan
1980
I
102% of die target.
The target for die_£asCzIUhW- efticiency
(% total estimated cases detected) was fixed at
44
33
0
31
___ J SP. PATIENTS
ALL PATIENTS
50
O
V
VI
VII
11 1
12.7
12.1
5.2
12.3
7.4
—5.L^
11.4
7.0
I’eivcnl
1980
5.4
0.5
10
1985
6.1
2.5
41
1990
6.8
3.2
47
J
A
''
SP. EXAM.
53____________
V
»
f
EVALUATION OF PERFORMANCE OF NIP
V.V. KRISHNA MURTHY
135
134
Table 10 Expenditure (estimated) on diagnostic and treatment activities in NTP during the VII Plan
TableS Pattern of drug Collection (standard regimen)
Average no. of
Drug collection (%)
Year
O’
5
4
1985
1990
l.j
41
30
4-7
8-11
13
15
19
18
12+
collections
26
37
7
Expenditure (in million Rs.)*
ii
Institution
X-ray
Examinations
Smear
Examinations
DTC
79.1
8.0
87.1
(60)
525.3
(51)
612.4
(52)
PHI
41.3
15.7
57.0
(40)
504.7
(49)
561.7
(48)
DTP
120.4
23.7
144.1
(100)
(12)
1030.0
(100)
(88)
1174.1
(100)
(100)
10
’Initial defaulters
previously undiagnosed sputum smear cases pre- ;J
increase, nearly one half of the CS attending Pi lls
were not examined by sputum. An almost similar
observation has been made by Seetha el al .
senting diemselves for diagnosis.
Treatment efficiency is defined as the propertion of cases converted to sputum negauve status J
•
at die end of die treatment period out of those put
Treatment activity
The annual report of NTP provides the pattern
of drug collection by a cohort of patients i.c. pa
tients diagnosed during a specified period, each
one of litem having an equal opportunity to com
plete the optimum period of 18 treatment months.
On an average, about 50,000 patients could be
thus observed for their treatment every year. The
percentage of patients put on treatment making at
12 monthly collections in 18 months ranged
least
from 26 in 1985 to 37 in 1990. The pattern of drug
collection by patients on SR, during die years
1985 and 1990 is given in Table 8.
A comparison of die pattern of drug collection
by patients starting treatment during 1985 and
1990 reveals a shift to die right in drug collection
during 1990, indicating improvement in drug col
lection. During 1985, 60% of die patients put on
treatment discontinued dieir treatment before
making dieir 8di collecuon, which got reduced to
48% during 1990; during 1985, 26% of die pa
tients made 12 collections or more compared to
37% during 1990, showing a 42% increase, lhe
average number of drug collections per patient
during 1985 was 7 as compared to 10 during 1990,
on treatment.
Programme efficiency is, then, die proportion |
Overhead cost not considered
Percentages within brackets
Table 9 reveals dial over a decade, about 501
•finding efficiency & pro- ■ —---------------increase in die case-finuiug
gramme efficiency, and a marginal increase in du
Health
Institution
treaunent efficiency have taken place.
Estimated expenditure on diagnostic and treat
ment activities during the VII plan
Efficiency of NTP
During die VII Plan period, 41 million exaiw
nations (X-ray and sputum) were carried out at*
6.3 million tuberculosis cases were diagnosed
two activities.
Case-finding efficiency is defined as the pro
portion of cases dial could be diagnosed out of the
Grand
Total
1
treatment widi SCC was insufficient.
activities of NTP : die efficiency of die pro
gramme mainly depends on die efficiency of diese
Treatment
more in DTC. Moreover, expenditure incurred on
of cases estimated to become sputum negative out y Diagnostic activity
X-ray examinations, over die five year period, was
of die total diagnosable cases in the programme t
During 1974, Naganathan ct al4 had estimated.
(product of case finding and treatment efficicnfive times dial on sputum examinations.
the cost of a smear examination to be Re. 0.54, 'd'vr. ■
cies).
land NTI had estimated die cost per X-ray exami
Treatment activity
The above diree parameters, at different points
lnation Rs. 4.00 (not published). Considering die
of time, are given in Table 9.
general cost escalation, the cost of X-ray and
In NTP, cases are treated eidier for 12-18
Isniear examinations now have been taken as Rs. ..
months (SR) or for 6/8 mondis (SCC). SCC was
Table 9 Case-finding, .'ealinenl and programme
17.00 and Re. 1.00 respectively. Based on die num-'
introduced in a phased manner in about 2(X) of 378
efficiency of NTP al different Mies
Iber of X-ray and smear examinations done during^
_____
districts, by 1989-90. ______
The expenditure
to be inkhe VII Plan period, an expenditure of Rs. 144.1 incurred on treaunent by SCC and SR
Efficiency
l was estimated
Year
million is estimated for diagnostic examinations'
....
on die
basis of die proportion of cases treated by
Programme
Treat
Case
Table 10), 60% of which would be incurred at
eidier regimen. The drug cost has been taken asment
finding
..y TI Cs. This estimate is> one and a half times that
Rs.
125/per
patient
on
SR
and
ncurred in PHIs, tliougb die proportions of total
Rs. 725/- on SCC. It was estimated that an expen- :
8
28
27
1980
uberculosis cases and sputum positive cases diagdilure of Rs. 1030 million would be incurred for
9
26
36
1985
. tosed in DTCs and PHIs were not different (Table
treaunent, shared equally by DTCs and PHIs; a to13
33
41
____ 9 >)• Hence, die diagnosis of a case appears to cost
1990
tal expenditure of Rs. £174.1 million foiuhe diae-
showing an increase of 43%.
Material for carrying out a similar analysis ot
Case-finding and treatment arc the two main
Total
Tuble 11 Cost of diagnosing a case (during VII Plan)
Expenditure*
(million)
New
X-ray
,
The financial requirement for die above two
Uvities have been estimated to be Rs. 1174 mi " ;
p- 12% on diagnostic activity and 88% on treat
ment.
Cases diagnosed
(million)
New
Sputum
Cost of diagnosis
(Rs.)___
Sputum
negative
Sputum
positive
Sputum
negative
Sputum
positive
DTC
58.8
6.0
2.6
0.7
24.92
90.00
XC
35.7
5.2
2.2
0.4
18.59
92.95
24.02
79.52
MC/RC
NIP
9.6
94.5
20.8
0.3
4.8
1.4
33.10
Estimated cost
cost of
of an
an examination
examination :: X-ray
X-ray :: Rs.
Rs. 7.00,
7.00, Sputum
Sputum smear by microscopy : Re. 1.00. Overhead
costs not considered
XC = X-ray Centre; MC = Microscopy Centre; RC = Referring Centre
II
■■■ J.IL-
—r?--—
■4
. *
v ♦
I
> ?
I
i
136
V.V. KRISHNA MURTHY
nostic examinations done and treatment given
during the VII Plan period. This estimate may be
viewed against die budoeuiry allounent of Rs. 600
million only for NTP during the said plan period.
Cost of diagnosing a single case
Under DTP, both X-ray and sputum examina
tions are done for diagnosing cases (sputum posi
tives or negatives) in DTCs and X-ray Centres
(XC), whereas in Microscopy Centres (MC) and
Referring Centres (RC) only sputum examinations
are performed. Based on die number and types of
diagnostic examinations done, die cost of diagnos
ing a case can be estimated. The estimated cost of
diagnosing a sputum positive case and a sputum
negative case is presented in Table 11. «
It is observed dial die cost of diagnosing a spu
tum positive case in a DTC (Rs. 90.00) and XC
(Rs. 92.95) is diree times dial incurred in a MC or
RC (Rs. 33.10). The observation, dial die cost of
diagnosing a sputum negative case (X-ray case) is
less dian dial of diagnosing a sputum positive case
should not lead to the erroneous conclusion dial
case-finding by X-ray examination is cheaper. It
should be borne in mind that cost estimates under
programme conditions, wherein Pills do many
sputum examinations to find fewer cases and
DTCs and XCs use both X-ray and sputum exami
nation and find more sputum negative cases, are
based on far more negative than sputum positive
cases diereby reducing the cost of diagnosis of a
sputum negative case.
Conclusions
effective and regular supervision and be
utilisation of trained personnel may impi
die quality of the annual reports.
4. Though there has been an improvemt
in the pattern of drug collection,
37 % of the patients put on SR made 12
more collections. Regular and adeqtt
supply of drugs to the PHIs may further ii
prove die drug collection pattern.
5. There has been a substantia] increase
the programme efficiency.
6. Nearly 80% of programme funds a
spent on treatment after excluding esta
lishment cost.
7. The cost of diagnosing a sputum posit!'
case in the programme was Rs. 79.5
calling for a more detailed analysis of co
effectiveness.
Acknowledgement
The author is grateful to Dr B.T. Uke, Directo
NTI, Dr A.K. Chakraborty, Addl. Director, Mr\
Murali Mohan Sr. Statistical Officer, Dr L. Sury;
narayana. Chief Medical Officer, for their vail
able suggestions, colleagues of Statistical Sectio
and Monitoring Section for statistical help, Mr (
Sathyanarayana & Mrs MJ. Jayalakshnii, Statist
cal Assistants, Monitoring Section for informr
discussion regarding functioning of NTP, Mr B.F
Narayana Prasad for graphics, Mr P. Pcrumal an
Miss T.J. Alamelu, for secretarial assistance.
References
1. The targets for die VII Plan have been substantially achieved.
2. There has been a substantial quantitative
1. Nagpaul, D.R. District Tuberculosis Control Pro
increase in sputum examinations done
and cases diagnosed, but the number di
agnosed is not commensurate with the ex
aminations done indicating that the qual
ity of selection for sputum examination
had deteriorated. Nearly 50% of the chest
2. Radha Narayan, Susy Thomas, Pramila Kumar
S, Piabhakar S, Ramprakash A.N., Suresh Td
Srikantaramu N; Prevalence of chest symptom!
and action taken by symptomatics in a rural com
munity. Ind. J. Tub.; 1976 23, 160.
symptomatics attending PHIs were not re
ferred for sputum examination. Neverthe
less, the contribution of PHIs to die case
finding activity had increased, coming
nearer to die expectations.
Annual reporting was not satisfactory. An
gramme in concept and outline : Ind. J Tub
1967, 14, 186.
3. Seetha M.A., Rupert Samuel G.E. and Parimall
N. Improvement in case-finding in district tuber
culosis programme by examining additional sputurn specimens; Ind. J. Tub.; 1990, 37, 139.
4. Naganathan N., Padmanabha Rao K, & Rajala
kshmi R.; The cost of operating and establishin
a tuberculosis bacteriological laboratory; Ind j
Tub.; 1974, 21, 181.
G .
kb’ .
: Sfl 46
speciality B. Will all these sources conji]|jja to subsidise for long the conferences
which are increasing in number and dost as time goes by?
A time has already cpqje when few apjpngst Pl can gffprd to attend a
conference at one’s own cost. On the other hmm, then is an immeasing tendency
on the part of the employers, both governmental and non-governmental, to
depute only those persons for a conference who have to present a paper. Will it
be worthwhile to hold a conference if only those who are to present a paper
attend it since their number is not likely to be large in a two or three day
conference and a conference lasting more than 3 or 4 days is virtually impossible
for reasons more than one?
Many questions aris$. Ar$ conferences jp such large npnjbers necessary?
Will the object of the conferences be defeated if their number js restricted? For
example, if the National Conference on Tuberculosis and Chest Diseases is held
in alternate years and in the intervening year conferences are held at State level,
would it in any way be detrimental to the objective? One may even go a little
further. Instead of each State organising its own conference in alternate years,
if three or four States could come together and hold a regional conference by
rotation in each state, there will be considerable saving in cost without any
reduction in scientific gains? Probably, the academic contents will even improve
as the conference will draw op the talents of 3 or 4 states instead d3±.cujng on
its own. And if such a course is adopted, the money saved tuereby can be div
erted towards meeting other even more pressing needs of medical and social
relief.
Doc« the prestige of a conference depend merely on its venue? Is a Con
ference organised in a 4 or 5 star hotel in any way more educative or informative!
than a conference erganisedin the unpretentious lecture hall of a college or any
other public institution or organization? Will it detract from the success of a
conference if much of the lavishness is replaced by some austerity? If the prime
object of a conference is education and scientific advancement will severe pruning
of the appurtenances reduce its appeal or attendance in any way?
These are some of the questions which everyone must seriously think
about. Matters are likely to come to a head sooner than later if the trends of the
last few years are allowed to continue unchecked. It is time that we consider
these issues thoroughly but dispassionately and take rational decisions in keeping
with our resources while retaining the academic benefits conferred by these
conferences.
C-Qi.-
■y/
.
: r.rsb
ret
r-...
\.
Ind. J. Tub., 1984, 31, 41
“OUTLOOK FOR TUBERCULOSIS CONTROL 2000 A-D."
K.N. Rao*
I consider it a great honour to have been tion in 1948 stepped up global tuberculosis
invited by the Tuberculosis Association
„ . „of India
v
control measures with the support of UNICEF
to deliver the second Robert Koch-Ranbaxy
I'
viz BCG_Vaccination: Chemotherapy; Research
Oration instituted so generously
\ byv Sri
ri Bhai
ai CfC jn developed countries these measure^Mohan Singh, the well known pharmaceutical wcrejrLaddltion to the socio-economic and
industrialist, at this National Conference on ' wcnare^ mc^Ijre^ such as nutrition,' housing,
Tuberculosis and Diseases of Chest. I thank elivfrbnmeiltr social security, health insurance
them for their kindness.
and health laws. The developing countries
under the guidance of WHO and IUAT took
2. Background
up anti-tuberculosis measures within their
resources to cover the entire population—•
Robert Koch’s epoch-making discovery of prevention by mass BCG Vaccination pro
the tubercle bacillus in 1882, changed the gramme, early detection of cases and domi
outlook for the control of tuberculosis until ciliary chemotherapy (as recommended bv the
the discovery of Streptomycin in 1944. In his Tuberculosis Chemotherapy Centre, Madras),
programme for combating tuberculosis he organisation of tuberculosis demonstration
recommended prevention of infection by & control centres, rehabilitation, research, etc.
isolation, of the patient in hospitals, screening
of the patient at home, disinfection of the patieThe Sth Expert Committee of W.H.O.
nt’s excretions. He further recommended the
(1964) standardised the Indian programme
. I
organisation_pf dispensaries, heaIth education approach for all developing countries The
of the population, particularly that of the District Tuberculosis Control Programme
patients’ and their families, and comt-L.
., through the existing health facilities is the keyiRulsory
rcgjstration of allj:ases._Even in his time, the
,K“ stone of the programme. This was later stream
incidence of tuberculosis was declining in_Europe'] lined, in the light of experience bv the 9th
with improvement Fn the sQcio-economic Expert Committee in 1974. /However, in
conditions of the people and the introduction majority of the developing countries there
of health insurance and social security for has been no improvement in the epidemiological
industrial workers. In 18X7, Sir Robert Philip situation. ~As a result of the Increase of populain line with Koch's ideas established the first tioh And a" stagnant socio-economic and nutri
anti-tuberculosis dispensary' which was the tion situation, there is an absolute increase
forerunner of the network of modern specialised in the number of Tuberculosis cases in these
anti-tuberculosis services
and dispensaries countries during the last three decades.
in the system of primary health care. The
Internajianal Union Against Tuberculosis which 3. Situation Analysis at Present
imposed an obligation on members was born
___________ •______________________________________ tx.
.
/. •
on
Oct. 1*7
17, 1O3A
1920 in ----succession
to the Central
Tuberculosis
of thehealth
leading health
tuberculosis
is one of istheone
leading
ro _
_...» ^....-1
•tflC ____
Pr<;v!?btlP*L
of Tuberculosis.' problems in South
A:;- t-dsy.
--1 E-East Asia
today. S:.?.-,
Sixty rlive
The developing countries for want of resources, percent
of
this
region
’
s
population
..
‘
— .-gior.'c pcpalaticr. of
cf one
men, money and materials had very meagre billion live in India.
.' SEA “Region
India. At present the
control measures. Towards the end of the has over kn_millionn estimated cases of which / / ^7
Second World War, the work of UNRRA and four million arc sputum positive.
voluntary
organisations
through
the
International Tuberculosis Campaign, was
The joint WHO/IUAT study group surveyed
commendable. The discovery of other drugs- the global situation in 1982 and considered
INH, PAS,
Thiacetazone.
Rifampicin, it a scandal that 4 million new highly infectious
Ethambutol,
Pyrazinamide, etc.
widened cases appear each year and a similar number
the scope of tuberculosis control/cradication of non-infectious cases of tuberculosis,
as a realizable goal in some countries. The particularly in children, also occur. At any
establishment of_____________
the World Health
given Organisamoment, the total number of cases
•President. International Medical Sciences Academy. RBA Buildings, Lal Bahadur Shastri Marg, New Delhi-3
Pa^Goa* RObCTt KoCh'Ranbaxy Ora,ion delivered at the 38ih National Conference on TB & Chest Diseases,
ic.N. raO
outlook Jon TtamcuLosa -Control 2000 a.d.
is of the order of 15 qi_2Q—million out of and recommended integration of tuberculosis,
which 10 million expectorate and about three- control measures in thc_Primary Health Care
million oeopk dic_ of Tuberculosis every approach for the attainment of the goals of
S-ThH^hsidcred a paradox in that we tuberculosis control ajd. health for all by 2000
have efficient means of prevention, case-finding A.D. In the field of Research in ‘uberculosis,
and complete cure. n is also a dilemma in that Immunology, Bacteriology, Short-term Chemo■ganisational,
andJ—the human factors therapy. Epidemiology, and Economics of
1 tfiflftnClRlj
---------- r-----jbstacies to the full application of Tuberculosis Control Programme were high
ctmstitute-obstacies
lighted. Ww’
•*
( available knowledge.
Tabu 1
4g
The main obstacles to the present National Primary Health Care: the Need
Programme which require improvement include •
the following :
'
*
Primary
health Care includes
eight vital
elements: neartn
health eaucauon
education;; looaanu
food and nuinuuu,
nutrition;
...
,
elements:
irM) The Ministry of Health requires strong provision of safe drinking water and sanitation;
central technical support'to guide and matemai and child health and family planning;
supervise the N.T.P. There is need for immunization; prevention and control of
improving the manageriaLtcani at the endemic diseases, appropriate treatment for
State and intermediate levels. The common diseases and injuries, the provision
programme specialists should Consider of essential drugs, the organisation of an efficient
themselves as specialised technical sup- referral system both institutional and laboratory
■ port to the General Health Administra- services and evaluation.
x
tion. Tha
The taame
teams ck/\itlr1
should con/a
serve nAt
not rtnlv
only
as specific programme specialists but
Dr. Mahler, in his address at the World
, v’- JhWSt also influence the functioning of Conference on Tuberculosis and Chest Diseases
the whole health system ;
1982, summarised that the future of tuberculosis
lies with Primary Health Care and Health for
2) the process of integration has not All by 2000 A.D. ‘Health for All’ means that
been properly a^reciated by all the there is an equitable distribution among the
members of the Health Services as population, of whatever health resources are
there is split responsibility^.
available, so that people will use the available
for better health care and that
the peripheral health services are approaches
health begins at home, in the schools, in the
inadequate to . icet the requirements factories
and in the fields. He also affirmed
of the total population;
that primary health care should by accessible
all with community participation, and that
4) lack of funds restricts all health activities to
will help themselves with their own
ihcludingtuberculosis control measures; people
health development. Dr. Mahler further stressed
the need for the New International Social
5) lack of continuous supply of drugs;
and Health order, tastly he implored that the
tuberculosis control programme be seen as
6) lack of training of key medical staff;
a stone in the construction of the health system
built upon Health for All and PRIMARY
7) lack of continuous evaluation;
Health Care; and that it is not for the stone
to decide its place but for the builder who selec
8) lack of community involvement;
ted it. There is no doubt that all Tuberculosis
agree with the above assessment and
9) lack of health services research in to workers
the problem of programme delivery; will help in this great adventure.
and
As the socio-economic conditions of the
10) lack of constant review of any variation people in the developing countries continue
to be stagnant, the quality of life as determined
in the programme
by P.Q.L.I. (Pyhsical Quality of Life Index
In addition, lack of good health behaviour based on Literacy %, infant mortality rate
of people, frequent transfer of staff and insuffi and expectation of life of the people) is below
the average 55 when compared to developed
cient salaries to them make the situation worse.
and middle income wnt-L.. ffable I)
The WHO/IUATstudy group(1981) meeting
P.Q.L.I. component indicators, per capita
which was considered as the meeting of the
F
te domestic product and calories intake
century, laid emphasis on socio-economic. State
jneasufes in addition to BCG' vaccination^for for Indian States (1971) with International
cEUdren, case-finding and chemotherapy, etc. comparison are shown in Table II and the rural
40
Average Per Capita GNP and PQLIfor 150 Countriee, by Income Groups, Early 1970s (Weighted by Population)
Total Population
(Millions)
Per capita GNP
(J)
PQLI
Low-income countries (N =42)
(Per capita GNP under $300)
1,242
155
40
Lower middle-income countries (N=38)
(Per capita GNP $300—699)
1,081
340
67
Upper middle-income countries (N=32)
(Per capita GNP J700-S1.999)
417
1 047
High-income countries (N«=38)
(Per capita GNP J2,000 and over)
1,040
4,404
92
All countries (N = 150)
3,781
1,476
65
& urban P.Q.L.I. for States in India in Table
111
Mortality has been reduced but morbidity
continues and the environmental factors remain
unchanged. The defaulters, relapses, occurrence
of new cases are indicative ortfie presence of
other factors. Thus tuberculosis prevalence
and incident in any country serve as indices
of the social organisation in the countries.
The greater prevalence of the disease in the lower
The urban/rural differences in the quality
of life of the people in India in different states
indicate that there is need for emphasis on socio
economic and nutritional factors along with
tuberculosis). Since the advent of chemotherapy
in Tuberculosis in 1944, so far the emphasis has
been on the drug, and the causative organism
without sufficient consideration to the other
factors such as environment and Nutrition.
Fig 1.
Drug
Bacilli
Ehvironmental factors Nutrition
x. .
,
, , ,
.
uugsuj, uic stauuai, me parauox ana
4-
the dilemma described earlier are the result of
Our t ,
vuvuxv, MAVlMfVJ T«UJ U,WV“
duced. Anti-bacterial therapy has its limitations.
different picture.
(
68
’
s e
China Concentrated on four key issues:
China’s three level health care net work; the
involvement of the people, the health man
power development and theTmancing of health
care through Health Cooperatives. China’s
tremendous political commitment to the task
of improving the quality of life of the people,
especially in the rural sector, may be well worth
emulation by the other developing countries.
While each country differs from others in
its historical, cultural, social, economic and
political background and circumstances, the
health care system in China presents many
useful points of reference for those seeking
primary health care in other settings. Even
with limited resources, primary health care
can be established and Tuberculosis Control
measures integrated. Political" w71T’ neonle’s*
^i^a£i0I}.’.cAponsiuii
exPansi0n oi
?f neaitn
health services lor
for
yrnuviyMivu,
primary health care, provision of uninterrupted
**
—
vuiuuuuii seem
to be the secret of success of the programme.
$■-
Table 2.
PQU Component Indicators, Per Capita State Domestic Product, and Calorie Intake for Indian States, 1971, *ith International Comparisons
Actual
Indexes uf
STATE
1. Andhra Pradesh
Life
expectancy
(Years)
Literacy
Infant
mortality
rate
PQLI
Life
Expectancy
1
2
3
4
43
47.7
54.1
28.2
56.1
SDP per
Calorie
capita (Rs.) intake per
(1970-71
day
1972-73
average)
Infant
mortality
rate (per
1000 live
birth)
5
9
7
8
109
303.7
2040
137
275.0
6
Egypt, Iran, Bolivia
Haiti, Papua New Guinea,
Pakistan.
2. Assam/Meghalaya
37
34.1
41.4
36.0
51.3
40
39.5
38.3
42.1
53.4
144
395.7
1612
Uganda, Morocco
3. Gujarat ^
48
46 9
61.3
35.8
56.3
93
300.3
2220
Indonesia, Lestotbo
4. Karnataka
70
63.6 .
77.0
69.3
62.8
58
302.0
1842
People’s Rep. of China, Columbia.
5. Kerala
6. Madhya Pradesh
37
45.9
37.8
26.6
55.9
145
262.3
2779
Haiti, Pakistan.
7. Maharashtra
49
46.4
55.0
44.8
56.1
107
422.7
2281
Indonesia, Honduras
37
37.4
428
31.1
52.6
134
254.3
Haiti, Pakistan.
8. Orissa
112
473.3
2832
Botswana, Burma
2044
Zaire, People’s Rep. of Yemen
64.3
28.8
52.7
67.4
50
9. Punjab
s
10. Rajasthan
33
32.1
45.9
21.9
50.5
127
310.0
11. Tamilnadu
46
43.1
51.8
42.8
54.8
114
355.7
1498
Iraq, Rhodesia, Tunisia
Senegal, Nigeria, Nepal.
27.9
25
12. Uttar Pradesh
42.8
42.6
40
ALL INDIA’
21.2
'W
Nations with same PQU
24.6
48.9
182
260.7
2307
34.1
54.6
134
349 3
1985
5
4-
weighted averages for all states and union territories except as noted in the appropriate
•The "ALL-INDIA" figure used here and in other tables that follow are
Census or SRS sources. They thus represent a wider coverage than the 12-state averages otherwise used.
.nrcrrt
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K.N. RAO
52
the disease process will be made in this decade made in other related areas will no doubt change
than in the hundred years since Robert Koch the outlook.
discovered the tubercle bacilli. Tuberculosis
The developing countries should encourage
immunitv is cell mediated. T. Lymphocytes
which react directly and specifically to antigens research in health education, econoniics_of
uw
wu
—
tuberculosis
control programmes particularly in
are responsible for the cell mediated immunolo
the integration of tuberculosis control measures
gic phenomenon. T
T. cells
cells do not themselves
l'"-;
effect the cell mediated antibacterial immuni in Primary Health. Care Health Services
ties but act indirectly through hormones— Research/Operational Research is of para
Lymphokines J that
they secrete. These mount importance and more so as the year
Ivmphokines have no immunological properties. 2000 A.D. is near. Can Indian workers make a
They in turn act through macrophages which are contribution towards this end? Yes, they can,
attracted to the site of (he lesion.'bacilli and if there is a will at all levels.
activate them to kill the bacilli and ingest these
The once high hopes for the speedy conquest
(see fig 2) is a virgin field production of
Lymphokines or anything stimulate their of tuberculosis likcTnose for malaria eradication
tpected have faded before the complexities of applying
production will help. Much was exj
is ----area available control technology, in developing
of Levamisole^New developments in this
countries. The governments of developing
are envisaged.
countries deplored the fact that little improve
ment had been achieved during the past two
Simple
Model*
of
cell
mediated
immunity
in
Fig. 2
decades. The Resolution of the World Health
Tuberculosis.
Assembly WHO:36:30 (Annex) expresses succ
inctly the present outlook and the need for
Antigens
concerted action.
+
Peripheral blood
Mono-nuclear cells
(T. cells. Monocytes)
5. Conclusion
I
I
T
The health of mankind requires the coopera
tion of the government, the people, the health
professions and the voluntary organisations
like the IU AT and its affiliates in the achievement
of our goals through PRIMARY HEALTH
CARE. The Tuberculosis Association of India
should spearhead the fight against Tuberculosis
through PRIMARY HEALTH CARE. AND
HFA by 2000 A.D.
\
It has now been realised that socio-economic
factors,standards of livingand nutrition enhance
resistance to infections. As one approaches
2000 A.Dr, along with new knowledge there
is also the fear of nuclear war, the building up
of armaments and the spending of resources
for the extinction of the human species.
_________l_
r
--1 on the principles
Economic
development
based
of the New
International------Economic
Order . is
Oi
.-.v.. ----------------paramount for the conquest of Tuberculosis,
9^„r and Koch
In --------------the meantime* “So tell P
Pasteur
or whoever they
, be, That they have not seen
the last of my comrades ana
Lymphoidncs
Cell or Cell contact
Macrophages
H2O3
Killing or
Inhibition of
M. Microti BCG
Research :
The areas of immunization, Immunology,
studies in geo bacteriology of the Tubercle
Bacillus, case-finding and treatment,particularly
short tc^mchemothcrapy.discoveryofnewantituberculosis drugs, epidemiology and sociology
of tuberculosis require attention. The progress
•••For Tubercle Bacillus'’ by James Hurd Keeling (1831-1909) From the Song of the Squirt—a
Koch’s Tuberculin,
satire o"
WJNDZR—TAI ORATION. 1981
Ind. J. T:ib , 1984, 31. 53
CHEST DISEASES IN INDUSTRY
P.A. Deshmukh
I am extremely grateful to the Executive
Committee of the Tuberculosis Association
of India for selecting me for this year’s Wander
F.A.l. Oration. I consider it an honour. I would
also like to express my deep sense of apprecia
tion to the House of Wanders for their
noteworthy contribution to the advancement
of medical science.
Early man lead a nomadic life. His day
used to be spent in hunting and fishing—arrang
ing food for his family. In searching for game
and green pastures for his herd of animals
he wandered from place to place. Seriously
ill and very weak persons could not stand the
rigours of hard nomadic life. Survival of the
fitt-st was the rule. Air was clean and forests
abundant. Man needed tools for his hunting
and weapons for defending himself. These
were made of stone, then bronze and then iron
was used.
As time passed, farming and housing were
developed. Man started leading a community
life and then he started discovering ways
and means to make his life easier—more
comfortable, more enjoyable.
It was noted that some rocks contained
substances which were of much utilitv. Mining
was started. As the superficial supply started
dwindling man started going deeper in the soil.
Proccssess were established to obtain a refined
product from the rocks which had to be crushed,
washed and powdered. And in this process
working persons had to breathe air containing
dust.
Turning back the pages of history, it is
seen that the concept of occupational health
is not a new one. It had its inception
antiquity. As early as Sth century B.C.. Hippoc
rates mentioned about the breathing difficulty
of rock miners.
Ancient citizens who were carrying a
mechanical trade had a social stigma. Socrates
is Said to have stated that persons who were
in mechanical trade were dishonoured citizens
as these trades damaged the bodies of the
workers and that they had no time to perform
the duties of friendship and citizenship. Thus,
the working man was neglected in ancient
medical practice. It was only in the 18th Century
that Ramazzini (1713). the father of Occupa
tional Medicine stressed the impoitance of
studv of working environment and its impact
on the human body.
With the development of science
anO
technology, new products for use in homes,
transportation, farming etc were developed.
Newer industries were established. With the
creation of new industries, working force,
mainly from villages started coming in urban
areas. People uprooted themselves from village
life and started settling at new industrial sites
in urban areas. In the beginning, they had to
face acute problems of housing and adjusting
to new environment. Housing shortage led
to breeding of slums in urban areas. Industries
added air pollution. In the developing nations,
industries develop in a haphazard manner
initially. They are established without proper
thought to their location, direction of wind,
disposal of effiuent. Developing nations want
to industrialise fast and in the process, the rules
and regulations about proper development
are ignored. It is only when industries get
established and start paying back that roads,
water supply, housing and medical facilities
are developed.
On the other hand, the industrial processes
themselves are in some respect a hazard to
human body. Today, I am devoting my talk to
diseases of the Lung in industrial environment.
While it may not be possible to include each
and every disease of the chest in industrial
environment, I will deal with the principal
diseases that one comes across in Industries:
I. Tuberculosis
2. Pneumoconiosis
a) Coal Workers’ Pneumoconiosis
b) Silicosis
c) Asbestosis
3. Byssinosis
4. Industrial Bronchitis and other respiratory
conditions
•Chest Physioan, Tam Main Hospital: Superintendent, A.M. Hospital and Professor of Chest Diseases, M.G.M.
Medical College, Jamshedpur.
HEALTH
Reprinted from Rhe Indian Journal of Tuberculosis, Vol. XXX, No, 2 April 1983.
TUBERCULOSIS CONTROL IN INDIA—CURRENT PROBLEMS AND POSSIBLE
SOLUTIONS
G.V.J. Daily
Attempts to reduce the problem of tuber
culosis through organised efforts had their
beginnings in India in the late thirties. With the
introduction of chemotherapy, organised home
treatment of tuberculosis from the TB clinics,
situated mainly in cities and district headquarter
towns, was started. The mass BCG campaign,
started in 1951, gave the first indications that
the problem of tuberculosis in rural areas
could be as big as that in the urban areas.
The need for extending case-finding and treat
ment of tuberculosis to the rural areas, in addi
tion to urban areas, was confirmed by the
sample survey (1) of tuberculosis conducted
by the I.C.M.R. The concept of offering tuber
culosis services as a component of the compre
hensive health care delivered by the general
health services was evolved in the country
over two decades ago. The concept has been
endorsed by the WHO (2) (3) and recommended
for application in its member countries in
accordance with the developmental situation
in each country. In evolving this concept,
cognisance was taken not only of the^sizc and
extent of the problem of tuberculosis but also
of the fact that the rural areas continue to
remain ill served. In the words of Morley (4)
“Although three quarters of the population in
most developing countries live in rural areas,
three quarters of the spending on the medical
care is in urban areas, where three quarters of
doctors live. Three quarters of the deaths are
caused by conditions that can be prevented at
low cost, but three quarters of the medical
budget is spent on curative services, many
of them provided for the elite at high cost”.
But, the picture is changing. Primary
Health Care, as enunciated by the WHO (5),
and to which India is strongly committed,
holds the promise that a drastic reallocation
of national resources will be made, in an all
ouV cffort to provide essential health care to
the rural population. The report of Working
Group appointed by the Govt, of India on
Health for All by 2000 A.D. (6) recognises tuber
culosis services as an important component of
Primary Health Care. The inclusion of tuber
culosis in the nation’s 20—point programme
is indeed the beginning of the realisation of the
commitment.
In dealing with the tuberculosis problem
and the National Tuberculosis Programme,
it is appropriate to realise that in the past, and
even to-day, several organisations, notably
the Tuberculosis Associations, institutions and
private practitioners have contributed consider
ably and continue to do so, for the alleviation
of the suffering caused by tuberculosis. However,
in this presentation on the problems of and
prospects for tuberculosis control in India,
the rural areas as also the National Tuberculosis
Programme have been selected for the main
emphasis. It is probably appropriate to do so
as that is where most of the problems exist.
1.
The Problem of Tuberculosis and the Prog in mine of Combat
The epidemiological dimensions of the tuber
culosis problem in India
India is one of the few developing countries
of the world where epidemiology of pulmonary
tuberculosis has been studied for a relatively
long time. In recent years, a large amount of
documentation has come to be available mainly
through epidemiological studies conducted in
different parts of the country. In most of these
studies, either one or more of the three main
epidemiological tools, viz., tuberculin test,
chest X-ray examinations and bacteriological
examination of sputum samples have been
employed to study one or more of the following
main epidemiological indices: prevalence and
incidence of tuberculous infection, prevalence
and incidence of abacillary and bacillary pul
monary tuberculosis, and prevalence and
incidence of drug resistance to the main anti-_
tubercular drugs.
Though tuberculin sensitivity in the general
population has been studied for oyer 40 years,
compar isons between findings at different times
and often between findings obtained at the
same time but made by different workers, is
beset with difficulties. This is often because
the tuberculin products used by investigators
at different times were different. The early
workers used old tuberculin(7) which gave
place to purified protein derivatives (PPD) of
tuberculin. In India the first PPD preparation
to be used was PPD RT 19-21(s) followed by
RT22(9), RT 23(10) Cl 1) and finally PPD-S(12).
In addition to changes in the product, criteria
for definition of infection have changed from
mere differentiation of an individual as ‘positive’
♦T.B. Specialist, National Tuberculosis Institute, 8, Bcllary Road, Bangalore-560 003.
Ind. J. Tub., Vol. XXX, No. 2
■
/■>,
.r-l
46
C-
(
G.V.J. BAILY
or ‘negative’, to exhaustive analyses of the
distributions of the size reactions(13). It has
also been realised that tuberculin reading being
somewhat subjective, the training and standardisation of the tuberculin readers was a
crucial variable not only for obtaining valid
findings but also for comparison of findings
at different times in the same population(14).
The methodology of such training and standar
disation of tuberculin readers has been detailed
recently(15).
Such methodological differences are not
necessarily without rationale. Technological
developments necessitated the methodological
changes. While such changes helped in obtain
ing better estimates of tuberculous infection
they also rendered the comparisons somewhat
difficult. Some of these difficulties can be
overcome through concurrent comparisons of
two or more tuberculin products in the same
individuals. More recently, study of the risk
of infection by converting data on the prevalence
of infection into risk of infection through the
method developed by the Tuberculosis
Surveillance and Research Unit of the
International Union against Tuberculosis(16),
some more problems can be overcome. Thus,
data on tuberculin sensitivity obtained at
different times by different individuals are
rendered comparable.
Changes in radiological and bacteriological
techniques have been less spectacular. One
of the main recent changes in sputum culture
techniques is the methodology of homoge
nisation of sputum samples. Change-over from
the use of oxalic acid(l) to alkali(l 1) for homo
genisation, has not greatly influenced the
estimates. As regards X-ray techniques, inter
pretation of photofluorograms taken in an
epidemiological survey, wherein most of the
individuals X-rayed have normal chest X-rays,
varies from reader to reader. In one study(lO)
the agreement between two readers, for photo
fluorograms read as ‘probably tuberculous
and active’, was only 55 % and for other less
definite categories much lower.
These arc only sonic of the differences
between different surveys done in India during
the past 50 years. Despite the above and other
differences, the data obtained in different
surveys provide a reasonable idea of the
problem of tuberculosis in the country. Table
below summarises epidemiological data as
obtained from some of the surveys conducted
in the country. The list is by no means complete.
Table
The prevalences and incidences of tuberculous infection, abacillary and bacillary cases as obtained in some epidemiological
surveys in India
(All ages)
Infection (%)
Author
Prevalence
1
Seal, ct. al. 1954(20)
2
3
38.9
4
5
6
7
8
0.39
0.14
11%
(of all
cases)
0.4
0.1
1.0
0.25
9
1.55
Raj Narain, ct. al. 1963(10)
38.3
2.0*
N.T.I. 1974(14)
30.4
1.77
Goyal et. al. 1978(21)
2.00
0.4
1.9
0.41
1.72
50
Bacillary cases (%) Isoniazid resistance (%)
Annual Prevalence Annual Prevalence Annual Prevalence Annual
Incidence Incidence
Incidence
Incidence
I.C.M.R. 1959(1)
TB PT 1980(12)
X-ray cases (%)
3.0
2.3
0.3
10% (
(of new
cases)
*Estimated from prevalence data
Ind. J. Tub., Vol. XXX, No. 2
4
TUBERCULOSIS CONTROL IN INDIA - CURRENT PROBLEMS AND POSSIBLE SOLUTIONS
None of the above data can be considered
as representative of the whole country or any
particularly large area. Indeed, it may well be
impossible to draw a sample representing the
whole country nor may it be necessary
to do so/fhe available data give us the follow
ing main epidemiological dimensions of the
problem of tuberculosis in the country:
(i) The prevalence of infection is of the
order of about 40% in all age groups
rising from about 2% in the youngest
age group to about 70% at'age 35.
Thereafter, it remains almost constant.
Incidence of infection is highest in
individuals between the ages of 5 and
20 years. The risk of infection is of the
order of about 2-4% per annum.
(ii) The prevalence of disease confirmed
by X-ray is of the order of about 2%
among total population aged 10 years
and more and pf these, about 20 per
cent (0.4% of total) are bacillary., The
annual incidence of new'cases is about
one third of the prevalence: 0.13% of
the total population aged 10 and above
becoming new bacillary cases of tuber
culosis each year.
(iii) The prevalence as well as incidence of
disease are higher as age advances
and again, higher among males than
among females, male to female ratio
varying from 3:1 to 5:1.
(iv) The incidence of disease, i.e., the number
of new cases occurring during a period
of time, among the newly infected is
substantially lower than those that have
been infected some time ago. Only a
fraction of all new cases occur among
those infected for less than 5 years.
(v) The trend of tuberculosis appears to
r
be almost constant over the years
except in some cities where better
services for diagnosis and treatment
have been available for some time(2l).
(vi) Tuberculous infection as well as disease
are more or less uniformly distributed
in urban, semi-urban and rural areas.
Thus the vast majority of pulmonary
tuberculosis cases arc to be found in
rural and semi-urban areas, where
more than 80% of the country’s popu
lation live. However, there are certain
pockets where prevalences and inci
dences are much higher than in other
areas.
47
(vii) Non-specific sensitivity is highly p~prevalent in the entire country though
there are significant differences bet
ween different areas: it is definitely
lower in areas situated at higher
altitudes(38).
Very little is known about the prevalence
and incidence of childhood forms of tuber
culosis in the community as most studies
reported uptil now deal with morbidity of
childhood forms of tuberculosis in the hospital
situations. However, from population surveys,
one fact is known: the incidence rate (risk of
disease) of bacillary disease among the freshly
infected (infected for less than 1 year) is over
fixc times that among those who are infected
for more than I year(17). If the risk of bacillary
pulmonary tuberculosis is so high among the
freshly infected, who arc mostly children, it is
quite likely that the risk of other forms of
tuberculosis is also quite high but the newly
arising cases of primary disease might go
undiagnosed especially in the rural areas.
Data on the prevalence and incidence of
drug resistance is conflicting. In a rural area
in South India, the prevalence of Isoniazid
resistance, among cases diagnosed in a survey,
is 12/^11). The spectre of increasing drug
resistance in the community may be real if
larger and larger number of cases are diagnosed
but treatment efficiency continues to remain
low. It may well be so with continued depen
dence on less acceptable standard chemotherapy
regimens along with increasing case-finding
efforts.
Thus, tuberculosis continues to ravage
India even 100 years after the discovery of the
tubercle bacillus. Indeed, there are some
indications that the problem may be showing
a slow, a very slow, downward trend (II) in
some of the epidemiological indices, such as
prevalence of infection in the very young
(0-4 years) age groups. Viewed as a problem
of suffering of the individual, of the family
and of the community, tuberculosis can rightly
be classified as one of the biggest public
health problems in the community especially
in the vast ill-served rural population of India./'
2.
The need for the continued study of epide
miology of tuberculosis in India
In the not so distant past, when epidemio
logical data in India were scanty, much reliance
was placed on the observations made in highly
developed countries. In the last few years, since
epidemiology is being studied more inten
sively in India, it has been realised that
Ind. J. Tub., Vol. XXX, No. 2
•i
48
G.V.J. DAILY
epidemiology of tuberculosis can be very quarter town. A stratified random sample of
different in different countries. For instance, the PHIs was selected and at each centre, an
in the BCG trial conducted in Britain, more investigating team identified symptomatics from
than half of the new cases of tuberculosis the out-patients and carried out sputum
occurred among those who, at the time of intake examinations. Extrapolating the findings in
were not infected, i.e., tuberculin negative(l8), the sample to the entire district it was shown
whereas in the (Chingleput) BCG trial conducted that, if all PHIs in the district participated in
in India, only 6 % of all new cases, occurring case-finding according to the recommendations
in the first 2| years after intake, occurred among i.e., examined the sputum of all new patients
the initial tuberculin negatives(12). The reasons attending the PHIs who are aged 10 years and
responsible for such differences may be attri- above
above and
and have
have cough
cough for
for more
more than
than 22 weeks,
weeks,
buted to differences in host response to nearly
nearly 2,000
2,000 bacillary
bacillary cases
cases of
of tuberculosis
tuberculosis
infection, or to environmental variations, or1 could be diagnosed during a period of one
differences in the characteristics of the infect- ;year. Considering
~ that' 15the prevalence of direct
ing organisms. For instance, it has been known smear positive cases in' i an average Indian
that the tubercle bacilli isolated from patients district (pop: 15,00,000), is about ?,000, nearly
in India are generally of a much lower virulence 65% of these cases could be diagnosed. The
than those isolated from British subjects! 19). study, thus, showed that the District TB
The epidemiological significance of this varia Programme has a considerable potential for
tion is not known. Similarly, the differences, case-finding.
if any, in the host responses of different popula
tions as also differences in evnironmental
Similar studies on the potentials for treat
factors, including the effects of the environ ment by the PHIs are not reported. However,
mental non-tubcrculous mycobacteria prevalent an operational investigation(24) was conducted
in the areas, is not known. Identification of at the main TB Centre in Bangalore to study
these and many other such undetermined factors the acceptability of treatment by patients in
demands an abiding interest in the study of the terms of the levels of treatment completed by
epidemiology of tuberculosis and extending bacillary patients of tuberculosis put on anti
it to areas of new interest. Further, India being tuberculosis chemotherapy with any one of the
a vast country, some epidemiological investi two standard regimens, Isoniazid and Thioace
gations will have to be conducted in more tazone (TH) self-administered daily and, Strep
tomycin and Isoniazid twice a week (SHTW)
than one area.
under supervision. The main results of chemo
The National Tuberculosis Programme therapy were assessed in terms of the bacterio
is essentially
a
permanent country-wide logical status at the end of one year as related
programme based on epidemiological, sociologi to the status at intake. While the procedures
cal and economic conditions prevailing in the of management of patients i.e., motivation,
country and integrated into the general health defaulter actions etc., were exactly according
and medical facilities at both the rural and to those recommended in the programme,
urban levels. The programme is organised and assessment of results was more intensive than
supervised by a nucleus of specialised staff at that recommended in the programme. Only 31 %
each administrative unit—the District Tuber of the patients put on SHTW completed at least
culosis Programmc(22). The implementation of 80% of their due chug intake while 56% on
the programme was begun in 1962 and over the TH completed 80% of their drug collections.
years, in 353 of the 401 districts, the programme Inspite of such a poor treatment completion,
has been implemented. More recently, with the 68% of patients on SHTW and 60% patients
implementation of the Health Worker (HW) on TH were bacteriologically negative at the
Scheme in rural areas, the health workers of end of one year. The drug regimens studied
the Primary Health Centres (PHC) have been have an efficacy, at one year, of 82-93% under
entrusted the tasks of case-finding, case-hold clinical trial conditions. Thus there is a potential
ing and B.C.G. vaccination. Discussed below gap in efficacy amounting to 20-30%, under
are the potentials and achievements in case programme conditions. Indeed, if relapses
finding and treatment of District TB Pro are taken into consideration, the gap may
gramme.
be larger.
An operational study (23) was conducted
in a district in South India to study the potential
case-yield by direct microscopy of sputum at
the peripheral health institutions (PHIs) viz.,
primary health centres, dispensaries and hospi
tals etc., all situated outside the district head-
Ind. J. Tub., Vol. XXX, No. 2
An analysis of treatment cards of patients
completing one year of chemotherapy in the
District Tuberculosis Programme in Bangalore
district(25) has shown that treatment completion
rates under programme conditions in rural
areas was very similar to that observed in the
TUBERCULOSIS CONTROL IN INDIA - CURRENT PROBLEMS AND POSSIBLE SOLUTIONS
•
49
operational study detailed above. On this basis
it is possible that the efficacy under programme
conditions in rural areas is also similar to that
observed in the study.
listed under three main headings: the structure ’)
or formulation of the programme, problems
of a technical nature, and problems of an
operational nature.
Though the studies on the potentials of
achievements in case-finding and treatment
under programme conditions stand in isolation,
observations on the functioning of the District
TB Programmes functioning satisfactorily,
suggest that these could be very near the truth.
Thus theJDTP, even without the contribution
that can be made by Health Workers, has the
potential to diagnose about 65% of direct
smear positive cases prevalent in the community
(or 45% of all bacillary cases), and render
about 60% of them abacillary at one year.
II.
The Current Problems of NTP
1.
The structure or formulation of NTP
Soon after the National Tuberculosis
Programme was launched many workers
realised that the programme was not function
ing satisfactorily. An l.C.M.R. Committee
appointed in 1975 for studying the functioning
of the NTP also made similar observations(26).
One of the reasons for this may be that the
formulation of the programme may not be
sound. The major difference between the earlier
3. The National Tuberculosis Programme— modes of implementation of programmes such
Achievements in Case-finding and Treat as Family Planning, Malaria, Leprosy, etc.,
and the Tuberculosis Programme is that the
ment
TB programme (case-finding and treatment)
A review of the
functioning of the was, from its very inception, conceived as a
programme in various States in India has programme integrated at the Primary Health
revealed that programmes are functioning at Care level. The basis of this concept towards
different levels in different States. As regards tuberculosis control evolved from a study of the
case-finding, while in an average District (pop: awareness and action-taking by tuberculosis
app. 15,00,000), the programme can diagnose patients in rural areas(27). The study demons
about 2,000 bacillary cases in a year, in one trated that over 50% of cases existing in the
State, nearly 1,000 cases are diagnosed—an community had already taken action by seek
achievement of 50%. In certain other States, ing relief from suffering at the existing health
acTficvemcnfs 'arc' far lower. The N.T.P. is, at services in rural areas. However, with extensive
present, functioning at a 30% case-finding observation made over the years that the
efficiency, i.c., each District Programme,’ programme was not functioning at the optimal
diagnoses about 600 cases per year. On the level, it may be appropriate to examine the
other hand, in respect of treatment, whereas relevance of the tuberculosis services as an
65% of cases diagnosed can be rendered integral part of the Primary Health Care. There
abacillary at the end of one year, in all proba are many ways in which such an examination
bility, the DTPs are achieving results very can be done. One of the most relevant ways
close to this potential. Thus, at present there would be to examine whether integrating tuber
appears to be a much larger gap in case-finding culosis services with the General Health
achievements than in treatment achievements. Services is in tune with the concepts based on
Indeed, neither the case-finding nor the treat which the mechanism of delivery of primary
ment potentials can be considered as satis health care has been evolved. The following
factory. Improvements in the functioning of have been identified as the public health
n.v District TB iProgrammes can
_ ___ __________________
j f rconcepts of health care at the primary level:
the
considerably
improve the case-finding but cannot possibly jep
(i) Cpmprehensive health care: curative,
influence treatment results to any great extent. '
preventive and promotive care provided
Improvement in case-holding demands that
from
the same services.
the technical and organisational methodology
of case-holding will have to be improved to
(ii) Regionalisation: each unit providing
obtain better treatment completion, and thus
such care be responsible for a defined
better treatment efficacy. The findings of studies
geographic area and population.
on the awareness and action taking by patients
suffering from pulmonary tubcrculosis(22) (23)
(iii) Evolution of the programme through
clearly show that a fairly large proportion of
evaluation.
patients attend the health institutions but
most of them are not diagnosed and put on
(iv) Services with stress on rural areas.
treatment. Prior to suggesting any solutions,
it is appropriate to identify the exact areas
(v) Services universally accessible: universal
where these problems exist. These may be
Ind. J. Tub., Vol. XXX, No. 2
j
50
G.V.J. BAILY
accessibility includes factors such
as travel distance and cost of service
to the consumer.
(iv) Acceptable to the individual,, the family
and the community.
(vii) Participation of the community.
(viii) The cost: The cost of provision of
health care should be within the means
that can be raised by the State without
detriment to other priorities.
radiographic deterioration during a follow-up
period of one year only. Thus, ‘suspect cases’
diagnosed at a clinic, where patients arc selfreporting or are referred, differ considerably
from those diagnosed in a survey and therefore
cannot be ignored. Certain degree of over
diagnosis is inherent in X-ray as a tool of
diagnosis. Whether this is also true of ‘suspect
cases’ diagnosed at PH Is which have an X-ray
facility, needs to be determined as, in future,
more and more PHIs are likely to be provided
with X-ray facilities.
b.
Even a cursory examination of these
concepts of Primary Health Care will reveal
that all these concepts, except possibly the
concept of community participation, are
satisfied in the mode of integration of TB
services at the Primary Health Care level. Thus,
the formulation of the tuberculosis programme
as an integral part of General Health Services
can be deemed to be sound.
2.
Problems of a technical nature
a.
Case-finding techniques
Two main problems relating to case-find
ing techniques adopted in the DTP can be
identified: over and under-diagnosis on sputum
examination, over and under-diagnosis on X-ray
interpretation.
In an effort to obtain estimates of over and
under-diagnosis by sputum examination by
the PHI microscopists, a study (29) was conduct
ed in 9 PHIs of Bangalore district. It was found
that under-diagnosis by PHI microscopists
as compared to well trained tuberculosis labora
tory technicians was of the order of 10%. On
similar terms, over-diagnosis by the PHI
technicians was of the order of 2% only. Selec
tion of appropriate samples for smear making
was identified as one of the main reasons for
under-diagnosis.
Under and over-diagnosis based on X-ray
reading is well known. In a longitudinal study
conducted in a rural community (11), it was
shown that only about 13% of those classified
as ‘suspect cases’ (C or D categories) and
not put on treatment, actually developed to
become bacillary cases during a follow-up
period of 5 years (30). It may, however, be
incorrect to apply the same figure to ‘suspect
cases’ diagnosed at a TB clinic. In a prospective
study(31) of the follow up of ‘suspect cases’
diagnosed in a clinic, it was found that over
50% of such ‘suspect cases’ are true cases of
tuberculosis as they became bacillary or have
Ind. J. Tub., Vol. XXX, No. 2
Treatment Techniques-Chemotherapy
With the observation that BCG does not
contribute to cutting down the transmission
of infection(I2), chemotherapy becomes the
sheet-anchor for tuberculosis control, at least
in India. The main technical problems in
chemotherapy arc drug resistance, prescription
of inappropriate drug regimens and, toxicity
and side effects to the main antitubcrcular
drugs.
Initial drug-resistance has often been cited
as a major problem in the management of
tuberculosis. Often it is difficult to determine
whether the initial resistance is primary or
acquired. In an analysis of the causes of
failure(32) of chemotherapy wherein the response
to treatment was analysed in relation to adverse
factors present at the start of treatment, it
was found that 63% of patients excreting
organisms that were resistant to the first line
drugs were bacteriologically negative at the
end of 2 years. Even the death rate among
them was not very much different from those
who had none of the adverse factors including
initial drug resistance. All the drug resistant
patients had been treated with first-line drugs
only, and their regularity was assessed as 80%
or more. Thus, initial drug resistance is relatively
un-important in deciding the success or failure
of treatment. It has been estimated(33) that if
in a community initial drug resistance is
present to the extent of 30%, it would only
account for 5% of the failures, the same cannot
be said of acquired drug resistance. Patients
with acquired drug resistance to Isoniazid,
harbour organisms that are resistant to higher
MIC levels than those with initial resistance
to lsoniazid(29). The chances of failure in them
with first line drugs are considerable. Possibly,
the main reason for development of drug
resistance is irregularity of treatment rather
than inadequate duration of treatment.
Despite the large number of clinical trials
done in India during the past 25 years, it is not
uncommon to come across inappropriate
TUBERCULOSIS CONTROL IN INDIA - CURRENT PROBLEMS AND POSSIBLE SOLUTIONS
drug regimens prescribed to patients even by
qualified physicians. Indeed the extent of this
problem is not known even in cities. This is
often true because some physicians and others
treating cases ol tuberculosis, especially in the
rural areas, have no access to recent develop
ments.
51
Drug toxicity is relatively rare for the socalled first line drugs and far more common
loi the second line drugs. Side-cITects, however,
arc common for some of the first line drugs
viz., PAS and Thioacetazone. These side
ellccts often result in patients being irregular
consumption if not a complete stoppage
duration ol chemotherapy are the two major
operational problems in case-holding. A very
large number ol studies investigating these
problems have been documented in literature.
In the study(24) investigating the efficacy of
two standard regimens under programme
conditions, the initial as well as subsequent
motivations of patients were done exactly
according to the recommendations. Further,
defaulter actions were also taken exactly accord
ing to recommendations. Even so, only 31%"'
of patients on SHTW and 56% patients on TH .
completed 80 () or more of their treatment.
The rates are only marginally higher than what
is observed in the National TB Programme. '
c.
c. Evaluation of Programme Performances
Evaluation of the impact of the programme
Evaluation ol programme performances
are made on the basis of reports prepared from
documents maintained by the DTCs. The
documentation in several DTCs is often in
complete and incorrect leading to inadequale,
inaccurate and rarely, even false reporting.'
Evaluation of the trend of tuberculosis in
the community becomes more and more
relevant as the programme gains momentum
and larger numbers of cases arc diagnosed and
put on treatment. 1 his is likely to happen
with increased investments for the control of
tuberculosis. The questions that may have to
be answered in the very near future are: what,
epidemiological indices should be studied?/
What tools should be used to study the selected
indices? How often and in what population
groups should these indices be studied? With
increased investments in the programme as
it is contemplated to-day, it is most likely that
the demand, for evaluation of impact of the
programme, will also increase.
All the problems that afflict NTP are not
without solutions. The very fact that in some
States the programmes arc working relatively
satisfactorily is proof that in other^States the
programmes can also work satisfactorily. The
following are the main areas in which some
solutions can possibly be found.
3. Problems of an operational nature
1. Allocation of priorities resources
a. Case-finding
Priorities are often allocated differentially
at different levels of health structure. For
instance, it is not uncommon to find that the
State Health Administration allocates the
highest priority to the Family Welfare Prog
ramme whereas at the basic functional unit
of the health structure, the PHC, the Medical^',
Officer allocates the highest priority to the
curative or clinical functions performed by
him. Though tuberculosis has been recognised
as a major public health hazard, the programme
has uptil now suffered because of the low
priority allocated to it among the various
public health programmes. Further, in the
tuberculosis programme itself, a disproportion
ately large priority is allocated to sanatoria.
Among all problems responsible for the
low achievements of the DTP, under-selec
tion ol patients lor sputum examination, is
probably the most important. The operational
,study(23) which measured the potentials of
case-finding at the PHIs, also showed that each
PHI would have to examine, on an average,
about 300 sputa per year from symptomatics
(new out-patients aged 10 and above, com
plaining ol cough lor more than 2 weeks) to
diagnose about 30 new bacillary cases a year.
The achievements of PHIs in most DTPs fall
very much short of this expectation. As stressed
earlier, the case-finding efficiency of the DTP
is about 30% of the potential. If the perfor
mances of the PHIs alone are taken into consi
deration the efficiency falls below 20%.
b. Case-holding
Irregularity of drug intake and inadequate
III. Some Possible Solutions for the Problems
of NTP
Inappropriate allocation of priorities infiuehces
the entire health care delivery . One of the glaring
results of such allocation is inadequate support
for the programme from higher authorities—
from the State to the district level and the
district to the peripheral level. At present it is
essential that the priority to tuberculosis among
Ind. J. Tub., Vol. XXX, No. 2
i
G.V.J. BAILY
52
the various health programmes and the priority
to different activities within the tuberculosis
services are appropriately realised by health
personnel at all levels.
Allocation of priorities directly influences
the allocation of resources. This is true not only
of India but also of many developed countries.
Four main resources of health care delivery
can be identified (i) knowledge of the state of
the art; (ii) facilities, including equipment and
supplies; (iii) manpower—professional, technical
and supportive: and (iv) money.
Knowledge determines the fundamental
character of the services provided. In recent
years, the knowledge on tuberculosis situation,
control and nature of services has expanded
enormously but has not percolated to the
personnel at the points of entry of the patients
to the services viz., the DTO, MO-PHC, etc.
This can only be achieved by appropriately
designed training and orientation programmes
to all levels of health personnel. This docs not
exclude the decision makers as well. The train
ing and orientation has to be uniform, con
tinued and tailored to each category of person
nel.
in the health services systems, they form only
a small fraction of the health manpower, the
para-professionals or para-medical personnel
far outnumbering the professionals. Inappro
priate training, utilisation or functioning of this
large group of personnel may even be harmful.
Orientation, laying down job descriptions and
more than all, supervision of these personnel
are essential for the proper functioning of the
programme. This will be obvious with the
enormity of the task faced in the recently
introduced health worker scheme. Another
shortcoming with regard to para-medical man
power is the availability of the appropriate mix
of this man-power. While field personnel are
usually adequate, laboratory technicians are
often lacking. This is mainly because the train
ing potential of laboratory technicians is still
small in most States. With increasing reliance
on laboratory technology in the diagnosis of
various diseases it is imperative that the train
ing potentials of the States, for this category
of personnel, substantially increased.
2.
Research
Continued study of the epidemiology of
tuberculosis has been stressed earlier. In addi
tion, what is probably more important, at this
Regarding facilities, it is not so much the stage of development of the NTP, are opera- _
availability of the best facilities that matters; tional investigations to improve case-finding
rather, it is the selection of appropriate combi and case-holding in the DTP. The present
nation or, what is termed as 'mix’ of facilities, techniques adopted for case-holding appear to within the resources that can be made available. be inadequate and other methods have to be
For instance, improving
A striking example is the demand for second investigated.
_
_ drug
line drues while the basic motivation and .collection by patients through motivation of the
in addific?
addition to th?
the patients, could
defaulter control measures cither exist oniy>, families (35) :::
in name or arc primitive. It cannot be denied^1 be tried in the rural areas, as this is feasible
that knowledge largely influences the allocation with the implementation of the HW scheme.
Similarly, especially in urban and semi-urban
of resources.
areas, a fair proportion of defaulter letters do
Manpower has been belatedly acknowledged not reach patients as the addresses given by
as the crucial resource. In the analysis of the many patients arc incorrect. In such areas,
problem of DTP, done earlier, it was obvious giving the patient an address-card so that he
that a large proportion of problems arc attri can return the same with his correct address
butable to manpower. As regards the pro entered on it by the local postman or a literate
fessional manpower such as the doctors, the person has been shown (36) to result in sub
problems faced are those of availability, orienta stantial improvement in getting correct addresses
tion or training, influence of previous training of patients. Similar operational investigations
and aspirations and utilisation of the qualified arc essential in many areas of case-finding, case
and trained doctors. Under-utilisation of doctors, holding and reporting, x
trained specially to manage the programme,
Valuable data arc now available on the
has been a major short-coming that needs
utmost attention. This applies equally to the behaviour of the tuberculosis patient towards
the available health services with regard to
other key personnel of the DTP.
diagnosis of their disease (27) (28). However,
In the last half a century, there has been an the reasons for default in treatment have been
enormous change in the nature of health man shown to be too many and possibly multifac
power. In the not so distant past, most of the torial, to be oTlicTp in effecting any changes.
health manpower consisted of health pro Sociological studies on patient behaviour to
fessionals such as doctors, nurses etc. To-day, wards his treatment have to be continued
•
“
I
Ind. J. Tub., Vol. XXX, No. 2
.1
k I -
t
r
. '
. •
I • * 1.
TUBERCULOSIS CONTROL IN INDIA - CURRENT PROBLEMS AND POSSIBLE SOLUTIONS
taking into consideration the multifactorial
nature of patient default. Another aspect where
in sociological research is needed at present,
is the mechanism and mode of obtaining
community participation in the tuberculosis
programme.
3.
Short-Course Chemotherapy
One of the most significant technical
advances during the last decade is the intro
duction of short-course chemotherapy. A large
number of clinical trials have been reported (37).
Several short-course regimens have been shown
to be of almost 100% efficacy under conditions
of clinical trials. However, little is known about
the applicability of these regimens under
programme conditions. Even with the high
cost of Rifampicin and Pyrazinamide, short
course regimens containing one or both of these
drugs for shorter durations daily or inter
mittently, and the regimens costing almost as
much as the regimen of Isoniazid with PAS
for one year, have been shown to have very
high efficacy. Side effects, toxicity and the
sense of well-being are factors that strongly
influence acceptability of these regimens.
Operational studies to evaluate acceptability,
in terms of duration of treatment and regu
larity, by patients treated under programme
conditions are essential. Further, studies to
determine whether self-administered domiciliary
treatment or supervised intermittent regimen
can be employed, have to be undertaken.
4.
The Health Worker Scheme
As a part of the provision of primary health
care to the rural population, a health worker
(HW) scheme is in various stages of implementa
tion in different States. A study (39) to investi
gate the feasibility of involvement of the health
workers in case-finding showed that each worker
can, on an average, collect about one to two
sputa per week from new symptomatics identi
fied during his visit to the households. He could
make smears and send them to the PHC for
examination. A little less than 10% of these
sputa were positive on smear. Thus, the Health
Worker could augment case-finding. Another
study (40) of the integration of BCG vacci
nation in the general health services indicated
that the services of the Auxiliary Nurse
Midwives (ANMs: who are now designated as
Female Health Workers) could be utilised for
BCG vaccination of infants without detriment
to the ANM’s other functions.
In the integration of tuberculosis services
at the primary health care level through the
HW scheme, various requirements would have
53
to be ensured: (i) training of the HWs; (ii)
supervision of HWs; (iii) provision of supplies;
(iv) availability of laboratory technician at the
PHC for sputum examinations; (v) method of
transporting slides to the PHC; and (vi) fixation
of realistic targets. In the study (39) quoted
above, the Health Workers of the PHCs were
trained in collection of sputum and making
smears at the PHC itself, for a period of two
days and even with this brief training, only 11 %
of the smears prepared by them were assessed
by trained laboratory technicians as unsatis
factory.
5.
Referral system
The NTP provides for referral of sympto
matics, whose sputum samples are negative on
D.S. examination at PHI for X-ray examination
at DTC. The X-ray results are referred back
to the PHI. It is common experience that only
a very small proportion of symptomatics,
referred from PH Is, actually attend for X-ray
at DTC. In an operational study (23) of the
referral system only about 10% of all sympto
matics and only 25% of the bacillary cases
contained among those symptomatics actually
reported at the DTC for X-ray. Referral of
patients and especially, referring the patient
back to the referring centre for treatment or
continuation of treatment are essential compo
nents of health care delivery. While this two-way
referral system has been formalised in the TB
programme it is not so for the other diseases.
Formalising referral will ensure continuity of
health care and will inspire confidence of the
consumer in the system. At present it is neces
sary that the two-way referral system is for
malised for referrals for all diseases and also
to carry out operational studies to identify the
reasons for non-reporting so as to strengthen
the referral system.
6.
Public Health Orientation to the programme
Any health programme, to function satis
factorily, needs a strong public health orienta
tion. Public Health Orientation in tuberculosis
includes: (i) simplification and standardisation
of procedures; (ii) relating achievements in
terms of quantity of activities carried out, in
addition to quality; (iii) periodic evaluation of
the problem of tuberculosis; (iv) invoking of
managerial techniques for improving the
achievements of the programme, and (v) im
proving accessibility to health care.
Simplification and standardisation of pro
cedures renders them suitable to be carried out
by para-professionals also. Professionals often
lack conviction in such simplified procedures
Ind. J. Tub., Vol. XXX, No. 2
54
G-V.J. DAILY
mainly because of the background of their
training. The lack of conviction is transferred
to the paramedicals also with the result that the
programme suffers. An obvious example of
this is the eligibility criteria for sputum exami
nation. In the NTP, all new out-patients at the
PH Is complaining of cough for more than 2
weeks are to be offered a sputum examination
at the PHI itself. Often, medical officers of Pills
by-pass this criterion and do not offer sputum
examination unless they suspect tuberculosis
on clinical examination, and thus miss a large
number of cases. The same is true of diagnosis
based on sputum examination and use of
standard drug regimens.
Relating achievements in terms of quantity
of activities performed by periodic evaluation of
the programme performances through ‘prog
ramme reports’ does not achieve the purpose
unless the reports are complete, correct and are
in adequate detail. Programme personnel often
are not oriented towards the value of this
activity. Evaluation of the programme per
formances through reports should therefore
include evaluation of the accuracy of reporting
in addition to periodic reorientation of personnel
preparing and submitting such reports.
The epidemiology of tuberculosis, unlike the
epidemiology of several other acutely mani
festing infectious diseases, does not demand a
constant monitoring of the epidemiological
indices for effecting changes in the programme
components. However, periodic evaluation of
some key indices such as risk of infection, is
absolutely essential. The questions that have to
be answered in this regard have been detailed
earlier.
Among the managerial techniques of direct
interest to the personnel of the NTP, super
vision of the programme personnel at different
/evels appears to be one of the biggest bottle
necks. The concept of ‘supervision’ in place of
‘inspection’ as practised in the past, has not yet
been invoked to any significant extent. This is
evidenced in supervisors demanding authority
over the supervised, resulting in a fear-oriented
‘inspection’ rather than a knowledge and actionoriented ‘supervision’. Indeed, factors such as
personal verification of problems of the super
vised by the supervisor, redressing of the
former's problems etc., are influenced by consi
derations such as availability of appropriate
facilities e.g. lack of facilities to travel for
supervision or lack of authority to remove the
impediments for a smooth functioning.
Accessibility of health services is another
mportant operational problem in seeking relief
lnd. J. Tub., Vol. XXX, No. 2
from suffering. Distance of the health institution
is but one aspect of accessibility. The other and
more important aspects which determine acces
sibility are, the quality of health services avail
able, attitude of the health institutions’
personnel towards patients, cost of services to
the consumer and the feeling of continuity of
service by the community. It will be obvious that
all these factors are lacking to a greater or lesser
extent in the delivery of health care not only
at the rural but even in urban areas. Indeed, the
enormity of the health problems and the meagre
resources available to meet these problems
cannot assure that all the conditions that are
conducive to improvement of accessibility would
be fully satisfied.
Detailed above are some of the main areas
wherein the solutions to the problems faced by
NTP can be found. It will be obvious that most
of the problems lie in the interaction of the
resources at our disposal. Technological and
other developments such as short-course chemo
therapy, health worker scheme and implemen
tation of research findings could achieve little
unless the most appropriate interaction of
resources is achieved. Formal research in this
direction may become essential especially when
increased inputs into tuberculosis control are
planned, as it is to-day.
IV The Prospects for Tuberculosis Control
in India
The level of epidemiological indices at
which an infectious disease can be considered
to have completed the phase of control, has
been defined for some infectious diseases such
as Malaria. This has, however, never been done
satisfactorily for tuberculosis. The rationale of
offering the definition; ‘1% infected at the age
of 14’ (42), as the point of control and the
take-off point of eradication, has been lost into
oblivion. At present, it may be appropriate to
examine whether such a definition of tuber
culosis control is at all necessary and if not what
would be the alternative?
All available knowledge about the epide
miology indicates that the tuberculosis situation
is almost constant in India and, if at all, showing
a very slow downward trend. The downward
trend is evidenced by the upward shift in the
age of first infection during the last few decades
and the possible gradual reduction in the inci
dence of childhood forms of tuberculosis re-sulting from the first infection. There is, however,
no solid proof of the latter. Indications are also
available that where the programme is good,
the problem of tuberculosis in the community
does show a downward trend (21). Direct
TUBERCULOSIS CONTROL IN INDIA - CURRENT PROBLEMS AND POSSIBLE SOLUTIONS
55
measurement of the reduction of the tuber
culosis problem, based on the estimates of
prevalence and incidence of disease in the
community, is beset with difficulties. It involves
repeated surveys, using X-ray and sputum
examinations, of representative population
samples. The samples will have to be very
large because the prevalence and incidence
indices are not only small in relation to the
total population but also the differences from
one time to the other, smaller. Such surveys are
expensive and time-consuming. In the event that
such direct measurements are not feasible,
direct estimations of problem reduction can be
made on the basis of the measurement of other
indices such as the risk of infection as stressed
earlier. However, indirect estimations of problem
reduction can be obtained from appro
priately formulated mathematical models. Such
a model has been attempted (41) using epide
miological data obtained under Indian condi
tions combined with hypothetical data on
programme performances. The very possibility
of such an indirect estimation of problem
reduction should be one incentive for obtaining
reliable data on programme performances.
Indeed the estimations can be checked against
the estimates of other epidemiological indices
such as the risk of infection.
with the solving of the operational problems
only, a downward trend in the tuberculosis
situation can be obtained. Invoking the techno
logical advances will indeed hasten this process.
By adopting such a policy of control, the reduc
tion is likely to be gradual rather than dramatic.
Such indirect and direct measurements of
the problem of tuberculosis will indicate the
trend of tuberculosis in the community. A
downward trend will indicate that a ‘policy
of control’ is in operation in the country.
Periodic monitoring of the problem reduction
and extrapolating it to the future will indicate
the time at which tuberculosis will cease to be
a problem. Thus, at the present stage, it is far
more important to adopt a ‘policy of control’
rather than to offer an epidemiological definition
of the problem of tuberculosis. With the avail
able evidence in India, about the inability of
BCG as a measure for reducing the trans
mission of infection, such a policy of control
can be adopted, at the present state of our
knowledge, only through adequate chemotherapy of larger proportions of cases prevalent
and occurring in the community. As at present,
when case-finding functions at about 30% level
and treatment efficacy at about 60% level, it
can be shown that per unit investment of
resources, improvement in case-finding would
yield higher dividends than improvement in
treatment. Indeed, when larger numbers of cases
are actually diagnosed, improvement in treat
ment results achieves greater significance.
REFERENCES
Indian Council of Medical Research, New Delhi—
Tuberculosis in India: A sample survey. Mono.
(1959).
2. WHO Expert Committee on Tuberculosis, Eighth
Report, WHO Technical Report Series, 290 (1964).
3. WHO Expert Committee on Tuberculosis, Ninth
Report, WHO Technical Report Series, 552 (1974).
4.
Morley, D. Lancet, 2, 1012 (1976).
5.
World Health Organisation. Alma Ata, Primary
Health Care: Report of the International Conference
on Primary Health Care. Mono. (1978).
6.
Govt, of India, Ministry of Health and Family
Welfare. Report of the Working Group on Health
for All by 2000 A.D. Mono. (1981).
7.
Benjamin, P.V. Indian Medical Gazette, 73, 540
(1938).
8.
Frimodt-Moller, J. Bull. Wld. Hlth. Org., 22, 61
(1960).
9. Kulbhushan, Nair, S.S.
and Ganapathy,
Ind. J. Tub., XVII, 19 (1970).
K.T.
10.
Raj Narain, Geser, A., Jambunathan, M.V. and
Subramanian, M. Ind. J. Tub., X, 85 (1963).
11.
National Tuberculosis Institute, Bangalore: Bull.
Wld. Hlth. Org., 51, 473 (1974).
]2.
Tuberculosis Prevention Trial. Madras. Ind. J.
Med. Res., 72, (Suppl) (1980).
Guld, J. Bull. Wld. Hlth. Org., 17, 225 (1957).
14.
National Tuberculosis Institute, Bangalore (Un
published data) (1962).
15.
Shashidhara, A.N. An Introduction to Tuberculin
Testing and BCG Vaccination, IBH Prakashan.
Gandhinagar, Bangalore-9.
16.
Sty bio, K., Mcijer, J. and Sutherland, 1. Bull. Int.
Un. Tuberc, 42, 5 (1969).
Thus, the problems faced in the control
of tuberculosis in India are pre-eminently
•operational in nature. It is possible that even
Ind. J. Tub., Vol. XXX, No. 2
\
56
G.V.J. BAILY
17.
Krishnamurthy, V.V., Nair, S.S, Gothi, G.D. and
Chakraborty, A.K. Ind. J. Tub.. XXXIII, 1, 3
(1976).
18.
Medical Research Council, Great Britain. Brit.
Med. J., 1, 973 (1963).
19.
Mitchison, D.A. Bull. Int. Un. Tuberc, 35, 287
(1964).
20.
Seal, S.C., Bhattacharji, L.M. and Banerji, A.K.
Ind. J. Tub., I, 3, 116 (1954).
21.
Goyal, S.S., Mathur, G.P. and Pamra, S.P. Ind. J.
Tub., XXV, 2 (1978).
30.
Gothi, G.D., Chakraborty, A.K. and Jayalakshmi,
M.J. Ind. J. Tub., XXV, 2, 83 (1978).
31.
Aneja, K.S., Gothi, G.D. and Rupert Samuel,.
G.E. Ind. J. Tub., XXVI, 2, 50 (1979).
32.
Pamra, S.P., Govind Prasad and Mathur, G.P.
Tubercle, 54, 185 (1973).
33.
Mitchison, D.A. Bull. hit. Un. Tuberc, 47, 9 (1972).
34.
Canetti, G. Am. Rev. Resp. Dis., 92, 5, 687 (1965)..
35.
Seetha, M.A., Srikantaramu, N., Aneja, K.S. and
and Hardan Singh. Ind. J. Tub., XXVIII, 4 (1981).
36.
Krishnaswami, K.V., Satagopan, M.C., Somasundaram, P.R., Tripathi, S.P., Radhakrishna, S.
and Fox, W. Tubercle, 60, 1, 1 (1979).
37.
Fox, W. Bull. Int. Un. Tuberc. 56, 3-4, 135 (1981).
38.
Raj Narain., Krishnamurthy, M.S. and Anantharaman, D.S. Ind. J. Med. Res., 63, 8 (1975).
39.
Aneja K.S., Menon, N.K., Chakraborty, A.K.r
Srikantan, K. and Manjunath, N. Ind. J. Tub.,
XXVII, 4, 158 (1980).
40.
Daily, G.V.J., Kulbhushan, Rupert Samuel, G.E.
and Keshavamurthy, B.K. Ind. J. Tub., XX, 4,.
155 (1973).
22. Nagpaul, D.R. Ind. J. Tub., XIV, 186 (1967).
23.
Daily, G.V.J., Savic, D., Gothi, G.D., Naidu, V.B.
and Nair, S.S. Bull. Wld. Hlth. Org., 37, 875 (1967).
24.
Daily, G.V.J., Rupert Samuel, G.E. and Nagpaul,
D.R. Ind. J. Tub., XXI, 3, 152 (1974).
25.
Seetha, M.A., Rupert Samuel, G.E. and Naidu,
V.B. Ind. J. Tub., XXIII, 3, 90 (1976).
26.
Indian Council of Medical Research: A Review of
the National Tuberculosis Programme—Report of
the I.C.M.R. Expert Committee (1975).
27.
Banerji, D. and Andersen, S. Bull. Wld. Hlth. Org.,
29, 5, 665 (1963).
28.
Narayan, R., Prabhakar, S.. Thomas, S., Pramila
Kumari, Suresh, T. and Srikantaramu, N. Ind.
J. Tub. XXVI, 3, 136 (1979).
41.
Waaler, H.T., Gothi, G.D., Baily, G.V.J. and Nair,
S.S. Bull. Wld. Hlth. Org., 51, 263 (1974).
Rao, K.P., Nair, S.S., Naganathan, N. and Rajalakshmi, R. Ind. J. Tub., XVIII, 1, 10 (1971).
42.
WHO Expert Committee on Tuberculosis, SeventhReport. WHO Tech. Rep. Series, 195, 12 (1960).
29.
Ind. J. Tub., Vol. XXX, No. 2
■
i iKl' 1 orxiu
X U 3 aJAC u
Ob 1
■
a
rhOUre-x^Iixi rOtbo 01;
BY
. '
EVc^UxiiluW
*
'
O.R.l^GP^UL •
IhxRGJUCTIOlM
Tuberculosis control entails introducing planned interven
tions) in the relationships obtaining at given times between tubercle’
bacilli and the people to render the epidemiological situation more
favourable to nan.
It is recognised that the interventions have to be specific
in nature,applied as a package of preventive as well as curative health
services made avail., ole to the people at different times in the life span,
of easy access and offered more or less on a permanent footing.
Past efforts to control tuberculosis in various countries
have had a long ana glorious history.^argely disjointed at first,these
efforts began to be better organised around the nineteen forties.The
term "tuberculosis control programme” was applied,then,to the more org
anised but differently planned and executed schemes such as opening of
tuberculosis clinics,establishment of rehabilitation colonies,etc put
together as one programme.
i.x.IIChrX TUBERCL^OSIb PROGR^s£( hTP )
Later,in the nineteen sixtees,emerged the concepts underlying
NTP.Enunciated in the eighth (1) and elaborated in the ninth (2) reports
of the VJHO Expert Committee on tuberculosis, KfP is now recognised as an
outstanding contribution made recently to tuberculosis control .technology,
Lately,the Joint lUhT/JEO Study Group on Tuberculosis Control has reaffirmed the principles underlying TTP,stressed certain selected aspects
and defined some aspects for further research (3).
advancing from grouping of anti-tuberculosis schemes,NTT
came out as selection of the interventions,in a planned manner,in acc
ordance with the epidemiological,socio-economic and other operational
considerations relevant to a country and knitted into a single co
ordinated programme comprising several activities.moreover,the activities
are applied
anti-tuberculosis services offered in integration with
the general health services (1,2) in order to cover the entire people
on a long term basis.
Almost all the developing countries are now implementing
nTF.These programmes,however,have attained vastly different levels of
development .and performance.^nd,efficacy of some programmes is not above
doubt.Therefore,we need to understand the reasons for such a happening
and evolve measures to correct the situation,wherever necessary,
r ROUrtAiU-'iE E Vzd-i Jx-tf I Uh
In order to understand the observed varying intensity and
quality of hTP performance as well as follow the epidemiological decline
and progress towards the a priori point of tuberculosis control (4),it
becomes essential to evaluate hTP methodically at regular intervals.
respite widespread awareness of the need to assess bTf.the
a
Evaluation 0 assessment are considered synonymous and have been
used interchangeably
/
- 2 reported assessments are few and far betwpen (5,6,7).One of the reasons
for this is that as yet there is no clear-cut,simple,applicable and
generally acceptable methodology for programme assessment.another,that
assessment of hfp would impinge, gather heavily on general health services,
which are being planned and implemented somewhat differently,since hTP is
. integrated with them.This is bound to cause misunderstandings and prob
lems which should better be avoided at this stage.Lastly,there is a
general though incorrect impression that the assessment process goes hand
in nand with apportioning of blame for poor performance ( Reading some
time to witch hunts ) and corrective actions lead to changes that are
exu^n cosmetic and unnecessary.human beings,understandably,try to avoid
both blame and change.Consequentlythere is ’little enthusiasm for prog
ramme evaluation and wherever it has been attempted ,it has been rarely
persisted with.
lixis paper is an attempt to project a comparatively clear
perception oi programme evaluation,discuss methodological options that
^ru available for adoption and encourage an assessment culture since in
its absence it would be like working in the dark.retailed work-patterns
have been avoided because assessment teams are expected Co draw up own
.assessment protocols and work instructions.
NTP IS u SYSTEM
To perceive evaluation correctly,one must first understand
the genesis of HTP as a programme.Parenthetically, a programme is a plan
or
procedurebto suitably deal with a matter or problem.Managementwise,
MP is a system comprising clearly defined objectives,resource inputs &
activities that lead to quantifiable outputs (8).uuring the programme
planning.it is decided which activities'' will be implemented and in what
quantities so as to fully justify the resource inputs i.e. .money,trained
manpower and materials made available for the purpose.kt the same time,
what outputs cculd be expected which would lead to the desired cbjectiies.
It is abundantly clear that despite the due planning process,
many do not subsequently treat NTP as a system.* majority of health admi
nistrators .trainers and tuberculosis field workers are drawn from the
ranks of those accustomed tc valuing health services for the "goed" they
de to the people and health activities as the means to do some good to
some people.Therefore,they are prone tc fault the people for not co
operating sufficiently with the health services and show impatience ,at the
same time,at the meagre resources placed at their disposal.The concern
whetner outputs that were planned to be delivered have infact been obta
ined cr not and if the several presumptions used during the planning
process have infact been borne cut during actual operation of NTP is qite
often not theirs.The legacy of the past is casting its long shadow on the
technology underlying NTP.
It is programme evaluation that enquires if the; programme
objectives have been achieved and,if not,why not’Further,it ■enables a
b
c
intutsCwirh rb-81SHler^tiOn °f «=civit^s that inter-link resource
with tn<. expected outputs, in a planned manner
ferSed in a ST °ne °r m2ny wcll-defiried homogenous tasks perx<_ruica in a. aeiimtu manner and order
4
the aspects enmeshed together.
’ (a) Holistic Systems Analysis
Mass BCG vaccination was perhaps the first to'be subjected to
this
assessment oven before BCG vaccination was made as an intgrated activity a sub-system of NTP (9,10).
j
The systems analysis method as applied to NTP as a whole was
reported as. early as 1962 (5): the premises on which the programme had
been based were re-checked and the programme outputs were matched against
the expectations.The study being seminal in nature,only two aspects were
presented namely that general health Institutions contributed as much to
case-finding as tuberculosis clinics and that patients were mere regular
in xtKiag ..rug collections if medicines Were iispuns.ed to them nearer
their homes irrespective of the kind of health institution which supervised their treatment.
Kn...e.s , tixt. protocol adopted for’that assessment was not so
sensitive as to adequately reflect the markedly different efficiency of
the specialized clinics compared with general health institutions,as is
suggested by Tables 1 & 2 derived from the data reported in that paper.
It would appear necessary that the assessment protocol adopted should
permit an in-depth examination of the performance in order to get at the
reasons for the observed deviations from the expectations.
IVrlf2i.nA.^2HSement oriented, the systems analysis method has
several advantages over other methods , the entire planning process can
be double-checked,differential allocation of resources tc the various
activities can be reviewed and changed suitably.efficiency of each acti
vity and each participating health institution can be Judged.administra
tive aspects like adequacy and timeliness of supplies and maintenance as
well as repair of equipment can
can be
be reviewed,frequency
reviewed,frequency and quality of su
pervision can be ascertained and,
above all,whether
and,above
all,whether the
the objectives of the
programme are being achieved,and to
can be
be estimated.Such
tc what
what extent,
extent,can
estimated.Such a
comprehensive insight could permit the programme tc be
replanned.
Essential requirements for this kind of assessment are a
highly trained team of technicians and
assessors,a central tehnical base
ef operations,such as natical tuberculosis
5 institute or demonstration &
training centre,a thorough''grasp by the team of the basis of planning of
that MT, correct, complete and up-to-date field records & reports .access
to mechanical or electronic data processing and a set of portable cardpunching machines for collecting data in the field without having f
remove records from the institutions assessed.An adequate budget,good
transportation facilities and close liaison with the corrective actions
taking setup are the other needs.
wany developing countries may not have the possibility at
present of providing the diverse requirements for the comprehensive
systems analysis assessment whenever such attempts have been made,these
have succeeded only for a short time.
(b)ASS£Soi<iEhT 01’ ACTIVITY EiTlCIEw/
simpler,mere practicalness expensive yet almost equally
d
th^potentinf
aCtj;vity is actual achievement as
a proportion of
Luc potential for achievement
- 6 •
casj-yiel.^ thus calculated with the potential case-yield estimated by
t.ic institute beforehand.Keeping in mind the weaknesses of the. data,it
was tentatively conclude.’/the centralized training had generally impr
oved outputs in case-finding,re-..uce . the extent cf missed cases and
reduce 1 ccnsi/urably the extent of .ver-diagnosis ( false cases ).k
shift of emphasis from radiography to sputum microscopy was also noted.
(c)
K^-d-iUhllerJ InROUGril CrdxdZ-xIIeixriL li^ICES
Some workers have adopted the method cf calculating a few
simple operational indices in respect cf each activity from the data in
the fi^l...an example is the undermentioned indices suggested in repect
of case-finding (16)and case-hclcing.
In<iex 1 » Number of now bucteri.Icgiqally positive cases cf pulmo
nary tuberculosis as a ...ropertien cf all tuberculosis
cases found including extra-pulmonary patients
In-.'.GX 2. New bactoriclogically positive pulmonary tuberculosis
cases placed cn treatment as .a pro pert ion of all pulmonary
cases treated.
Index 3. zdiiong the newly discovered bactericlogically positive
cases the preportisn without history of previously recei
ved specific treatment
Index 4. Lumber of bactericlogically positive cases cf pulmonary
tuberculosis diagnosed by the institution as a proportion
of total cases treated by the institution
Index 5. Lumber of bacteriologically positive cases lost sight of
in one year as a proportion of all the cases Create^.
1’his method though very simple has much greater limita
tions compared, with the preceding methoe.
(d) Erl^uIouGGlUvL I^PrxCT EVr-.LUziTIOL
Seme workers have tried to evaluate LIP in terms of the
etiological impact proeucuo by it (17,18).No doubt,the classical
epidemic logical survey can be- repeatec at intervals of five or ten years
to measure declines m the main cpiuetni< logical parameters .Yet, there aie
two more reasons for using the survey method for evaluating NTPtmcre
often than nct,tne hij? objectives are j-.rmulatec in epidemiological
terms ana, sec nd.ly, there is f ir greater familiarity with survey tech
nique compare^ with operational assessment.
oince KIP is a system,it stands to reason that its obj
ectives should be set in quantifiable ojerati<.nal terms.lt is quite
vague, cherefore, to aver that objective ci KIP is to- control tuberculosis
in the forseeablc- future |unrealistic
to set down that MP should lea<r /
to s..xy incidence of infection of jnc- percent or less per annum or pre
valence cf infectious cases to less than one per thousand population K J
more appropriate to set the aim at finding say two thousand sputum pos
itive cases pur annum in a district ef one million people oc so on.
ihere are several ccnsi orations that go against the
epidemiological evaluation muthoc^iiunges in epidemiological parameters
are normally sc small and take place over such a long period of time
tnat fur all intents and purposes no impact can be reported reliably
" 7 "
I
1
(17,18).Best cs,surveys are bound to interfere with routine programme
'ictivities.x'-i'Ku,surveys need a very hi,d.i lev^l of technical expertise,con
sistency from one survey to another and very large budgets.Even when ■
some impact io found,there is no way to ascribe it to 1\TP and not some
non-specific factors cr even the normal secular decline in the epidemic.
Lx survey metin .i, therefore, is best reserved for estimating the size Gf
the prcblera and tirar
fpr prb>granune evaluation.
<o)
o001 uijuCr_o .-xSodeonjO ■ x
lubcrculusis is in essence a problem of human suffering,
anv.,n?..re the tuberculosis services are able tc roach the people,the more
is suffering alleviatea.The question really is how to measure the relief
from suffering thus provided by hTP ana/the measurement to objective
setting of Mr.
Untimely death caused by tuberculosis is perhaps the
ultimate in human suffaring.Compare^ with crude mortality,specific death
in the population is more in all the age 6c sux groups.If and when the
MP services reach the people and. are effective, specific mortality shcull
gradually decline to come closer tc cru.e mortality in all the age-sox
_.raups. ibis measurement could be dovelope.: into an index of sociological
assessment .tx st art could be made with c?.se-fatality rate. It has been
-.bscrvod that early .ieath is quite hi,_.h among cases placed cn treatment
under Mr and is showing no- sign M coming down,perhaps due to late
uiagnesis.ix rtality among bactcriologically positive cases found and
to
tru.itvG ‘ under Mr should come clcso/tho rates recorded am<_ng treated
cases in the several controlled clinical trials.If diagnosis under Mr
is made early enough and case-holding is steadily improved,the case-fu
tility rate is bound to gradually full to more acceptable levels'.
Similarly,a physical suffering index could be devoid-ed
cn t:x basis c.f average curation'c.f suffering prior tc diagnosis, in a
district or health instituti :ns of different kinds.higher the awareness
ano. oct ion-taking among the people ( an indirect success of Mr ) or
grc.'.t^r the efficiency of Mf,lesser should be the avertige duration of
synipck-iiiS prior to diagnosis .x- base-line could be established on the
average duration of symptoms jricr t. diagnosis in an area/institution
before implementingi'-Tr.
ddrExkvxoIUh , Lxel ,11 eMi't’u- 6c i-xoSdool iEi .J?
There is sometime cc-nfusion between the terms supervision,
monitoring and assessment connected with programme management.while the
first two are more commonly applied,assessment is done but rarely.The
t^-rm ".Tiunitoring assessment" is ■ misnomer.
bupvivisicn examines if the i re.gramme activities are per■‘-'-■rmkjd ■_.;.ccorcin,^ t<_ tne manual ana, if not..,why not.'monitoring,on the
other hanu,keai.s a close and constant watch on the periodic reports to
judge if the system is working as expected (8).assessment is different
both in character uno scope:it examines quantitatively,ncn-subjectivoly
and indepenaently of the system,if the programme objectives have been
achieved and,if net,why nuf.'Thero are seme other differences too:
Supervision is exorcise.1 by the next higher level health
I
/
i
’i
'I
-1... titutilGn t LEGU^h airGct
staff
-c^rn-
f
-A^rv-dn cf uaeh activity,discussion with
r_i.n.> the ooservaticns,formulation of rcccmmenx.. r.G
Jcrr^et .ve ctions •ftll.rweJ. by seme actions taken on the
“ I- ' r
;u: ervis r requiring- training/re-training ex the rest cn ret: ir.n to i...
.rtcrs waicn ccnccrn
a
- a..,jinistrative
matters.
■- tin; LJ . _ne by statistically trained
staff at the state/
X
- lcv_ .Out uts c 'it^Ln.e>. in
t_'e
scrimes... periodic reports are
... '-...n.fi.-u„u.,l'.- \ J.th c.
—K-xpuctations: if there are wide G or
ri...;l.
,,tae
t.A.„ u?l. ..v/cr-... supervisory team is alerted to study
i
t
■.. ..1 the
ts
r
"
j-ru.r.tikii arid ccrtvctive actions.
ikssess.tenfis ;ae dy o. highly trained team cf assessors at the
central level ,whc . ^..t
research
preach,collect their own data that
enables the.-, t re ten . reciso an. otjecjjve findinSs, leading to recomm-
Wr® .
w-uc*1 S1;-Ui
e nveye... te/che fti? levels f,.r Corrections.
-nclusi a,it e-.y de sei . that we are faceu with a situation
° untries wlth ^tionnl tuberculosis programmes ate neglect^
\
rame assessment..sesiees the obvious handicap of having t
■ LnC
- tact
is the target\f
r^Ce
6ettins su—« and,more i.^rt..nt; ;.n o ; rtunity
'
X
through assessment.Ihe problem of finding
— appropriate methodolc^i .-..ul.. fee reSelve. by trying the alternatives
dlSCUsau<
ve
understanding the pres & cons better than new.
•=« ^rculosls-SthSeport.Tech.Xep.Ser.^SO (1964)
2'n
^-crt.lech.t.ep.eer.,552 (1974)
3...‘lui'/^0rj
-.
*
Expert Committee n TubercXis 7th H eonE^lsIech-^-3^--6710®)
©O'Rourke J. Evaluating ’ -.ntTl
c ‘., 1 55 (1960)
Xatar.
■■
a.
1 ^Sramme-sjind.J.Tub.lZ.a.S? (1965)
' ■O’
1®
11.
55,O9 .Supplement (1980Q7. Bally e' V.J.
r c
-r Beer vnccinati; n:Bull.eev.Irev .IB..9,12 (1962)
8. NaSpoul o0RoS -•nt rd x to , .i-a
tuuerculeSiS!Pr&OOB,.in ;S Of the IX
.f
f.:stern Rc,; dn e nlv
-..<-rGncfc ..x lbz..i ,i\ie-w xjolhi,j .55 (1974)
S.tokhtari L.et ;,liStudy
1.0 X ^i.11 xi ..
• cc Hr
S1-. .
n.
-.Gothi
- .b'-Q vpaul
14.3aily G./
15 o
1
e
. 1.--'
i/.Gctui
ic.Gcyal
: i
r;
1
n .
i~lv" t i a.j. e
-T7444^197p)BCG camPai£5n
l.Uati.
’’Sr'Ull,
cv .luati.n
-i. - BOO programme;Bull.I.u.ft.X.,
50,2,113 (1975)
.Ik-. tontial yioi . Cf c-ll,
cases „f.pulmonary tuberculosis
•■•y ...district Of South'
— in. ia;Bull.,iid.r.lt;37 ,S 15(1967)
de d jCases , . t ...men . outpatients
tituti’Asf/\fIiXur
h«alth 1ns’--------G"iit:n’Or •■•43,35 (1970)
’*<• ,ct al
SM, Stuy.f ufa-i
in - 1 r.ci.
I
:X7' -IW'TB CUnic
• ,et alia cuncurrurit Camparis n -f - •//
fully su . rvis’.^rtrt--”-1. n ^K-rvisee ... end a
. .
cutj tients tre tment"■■/■'rvfxnc® 1/1 a routine
tential f passive case-fi^/i-•J -rub. -,21,3 (1974)
iMBeXiMnlnsular
.1 -•.ysi-) ■ Bui 7
/ •'•”"? n lni2-.-^ted progr- •, ct
- Staple indices ferfwi^in’^^’^ntlS-Zb
. dab;
:
»ct al»Prevalence l_“
Initial
^l0’after
ru“"rCuitIis\rc^^^
_
-
—
----------------------
a_ kJ
’TuL --- 3 J21
979^1V"/
<X-
i1
'
25,2,77 <1978)
(1978)
Urjan ^inuuitysIncl.u .fub.;
kft
>
TABLE 1
NEW CASES DISTRIBUTED ACCORDING TO THEIR PLACE OF RESIDENCE AND TYPE
OF HEALTH INSTITUTION MAKING THE DIAGNOSIS (FROM 16.8.61 TO 15.8.62)
Number of Cases found by
RESIDENCE
TB Clinic
Major Hospitals
All
Minor Hospitals
& Health Centres
No.
%
No.
%
Within same town as
diagnostic centre
593
29
801
56
1,140 83
Outside same town but
within same taluk
563
28
460
32
228
Outside same taluk but
within district
857
43
176
12
2,013
100
1,437
100 *
No.
%
No.
%
2,534 •
53
1,251
26
1,033
21
4,818
100
i
TOTAL
1,368
17
100
□
Cases are both bacteriologically and only radiologically positive diagnosed through different facilities provided in different
□
health institutions.
Of total 4,818 Cases, TB clinic found
42%, two major general hospilals 30% and 1 2 minor hospitals / health centres Jg%.
Respective catchment area populations were 10%, 10% and 80%.
TABLE 2
Cases found between 16-8-1961 and 15-12-1961 completing nine monthly drug collections on or
before 15-8-1962 distributed by place of residence and type of health institution giving treatment
Proportion Completing nine Collections at
Residence
Within catchment area
Outside catchment area
Total
TB CLINIC
GENERAL HOSPITALS
39% of
38% of
44% of
336 Cases
210 Cases
438 Cases
20% of
14% of
14°/
1 ^/o of
383 Cases
244 Cases
29 Cases
29% of
25% of
42% of
719 Cases
454 Cases
467 Cases
HEALTH
CENTRES
TABLE 3
A Comparison of case-finding outputs and case-yields in PTS clinics
and NTP health Institutions of MOH from bacteriological/radiological
examinations done prior to centralized programme training & after
wards with estimated case-yield potentials
PERFORMANCE OF
TB CLINICS (PTS)
NTP
(MOH)
1974-76
1979-81
1974-76 1979-80
94,137 189,574
A.
Average new sputa examined
per unit/entire NTP annually
1,350
1,484
B.
Average new cases found per
unit/entire NTP annually
325
190
7,556
17,931
C. Case-yield (B/AxlOO)
24%
13%
8%
9%
D. Estimated Case-yield potential
10%
10%
10%
10%
E.
Average new radiogramms taken
per unit/entire NTP annually
3,584
3,429
F.
Average new suspect cases found
per unit/entire NTP annually
1,197
688
31,611
21,758
G.
Case-yield (F/E x 100)
33%
20%
8%
9%
H.
Estimated case-yield potential
12%
12%
12%
12%
413,975 233,988
PTS : Philippine Tuberculosis Society Inc. maintains a network of tuberculosis Clinics,
apart from NTP
MOh : Ministry of Health has organised NTP in the Country with general health
institutions and a few tuberculosis clinics
II
COMMUNITY HEALTH CELL
47/1,(First Floor)Sc. Marks RoaReprinted from Journal of the Indian Medical Association,
'
BANGALORE 001
Vol. 71, No. 2, July 16, 1978, Pp. 44-48.
Tuberculosis in India—A Perspective
D. R. NAGPAUL*
Although tuberculosis is known to have existed in India
from time immemorial, not much is known about how it was
distributed, its spread, and the disease trend till lately. Much
of the inform ition in the Vedas and Ayurvedic Samhitas deals
with the prominent clinical features of the disease and the
kind of patients who might respond to certain treatment.
Neither notification nor health statistics existed then, that
could have thrown light on the rise and fall of the disease in
the country. The information that has become available over
the last few decades, excepting properly conducted epidemio
logical surveys, also is not very reliable. Therefore, conflicting
claims are often made about the disease being on the increase,
endemic or declining in the country with no means available
to confirm the claim.
TUBERCULOSIS EPIDEMICS:
I
Liki acute infectious diseases, the chronic infectious diseases
also spread in conminilies as epidemics. But, the charac
teristic secular curve of the epidemics is not easily discernible.
Complete information about a tuberculosis epidemic is not
available in any country of the world. In some European
countries notifications of tuberculosis deaths became a regular
practice from late 18th century andthe mortality curvesdrawa
on this basis suggest that a tuberculosis epidemic may last from
203 to 493 years (Grigg, 1958). Ifso, the doubt arises whether
ancient countries with thousands years of tuberculosis expe
rience have had one or several tuberculosis cpdemics. In
view of paucity of information, some degree of conjecturing
m ly be permissible on the basis of the known facts.
For projecting a proper conjecture one must also draw
upon the accepted typical features of the disease during the
ascending and descending phases of the epidemic. During
spread of the disease in “virgn soil”, the infection, disease
and death rates are all high and there is I i t tie difference between
them; the dsease is acute, rapidly progressive and often fatal,
and is concentrated among the young as well as the city dwellers
wao live under conditions favouring dissemination. Spread
to rural areas occurs much later, but in a very similar manner.
During the descending or waning phases, however, the above
mentioned rates are not only comparatively low but very
different from each other. The disease now is chronic, slow
or indolent, fibrotic, not so fatal and concentrated among the
elderly. During the endemic phase, all the features of the
waning phase^prevail but, barring the temporary fluctuations,
thereis I it tic or no change in the various ratesover long periods.
Grigg (foe. cz7.) also made several other significant obser
vations about tuberculosis epidemics, based on theoretically
drawn epidemic curves supported by many a piecemeal obser
vation from several different countries. Thus, the tuberculosis
epidemic curves of different countries or the different regions
of the same country may appear to be different (but arc not
really different) due to varying socio-economic environment
and resultant host-parasite relationship. Similarly,the peaks
National Tuberculosis Institute. Bengalore
*B.Sc., M.B.B.S., T.D.D., Director
of tuberculosis infection, morbidity and mortality may occur
at different times and to different extents in a country for
different age, sex and ethnic groups. In other words, toi
gauge a tuberculosis epidemic in its true perspective, a broad]
review spread over as long a period as possible is necessary,!
because the statistics of a decade or two, collected from differena
regions and selected consciously or unconsciously for diffrenq
reasons, may more often mislead than tell the true position.
TUBERCULOSIS IN INDIA :
With regard to India, no direct evidence is available as to
the number of epidemics that the country has had so far, nor
is the true position on the current tuberculosis epidemic curve
known.
The most prominent findings of the National Tuberculosis
Survey (ICMR, 1959), Tuberculosis Prevalence Survey in
Tumkur (Raj Narain et al., 1963) and Tuberculosis in a Rural
Population of South India, a five-year Epidemiological Study
(National Tuberculosis Institute, 1974) are that (i) the tuberculosis morbidity in India is largely confined to older age
groups, (ii) prevalence in the rural areas is similar to that in
cities' and (iii) the gap between infection and disease rates
(38 per cent and 0.4 per cent respectively) is very larger indeed.
All the 3 features satisfy the already mentioned characteistics
of the declining and or endemic phases of the epidemic. Being
a scientifically collected epidemiological information, it should
reliably mean that the epidemic is waning or has become
endemic.
The tuberculosis mortality information for India being
deficient and not very reliable still apprears to suggest that the
disease since the turn of the century has followed the same
general trend as in some western countries endowed with the
requisite notification data- Rogers (cited by Lankaster, 1920)
at the time of World War I had estimated on the basis of post
mortem findings spread over 22 years that 17 per cent of the
total deaths in hospitals were due to tuberculosis. The decen
nial estimate of crude mortality during the 1911-21 census
period in India was 47 per mille. And, on that basis, the com
piled tuberculosis mortality would be 800 per 100,000 persons,
if hospitaldeaths were truly representative of the general deaths.
Lankaster (Joe- cit.'), after taking note of Roger’s estimate of
tuberculosis mortality, also quoted the other available statis
tics: Calcutta 2.1,Bombay 2.8,Madras 2.5and Ahmedabad 5.9
per mille, and felt that the actual tuberculosis mortality would
be 4 per mille or higher in most of the Indian cities. But, that
was just about the position in Czechoslovakia (Radkovsky,
1959) around 1880 i.e., 40 years earlier. In any case, this is
the earliest available rough estimate of tuberculosis mortality
in India. ( McDougal's (1949), estimate of the specific mortality
around 1949, however, was 200 per 100,000 persons whereas
that of Frimodt-Moller for the same year for the Madanapalle
town and surrounding area was 253 per 100,000 (FrimodtMoller, 1960). \Frimodt-Moller further reported that the
mortality in his study area was reduced to 64.1 between 1951-53
and 21.1 between 1954-55 per 100,000 persons, which he could
not explain except due to a natural decline plus the rigorous
tn
O'
antituberculosis measures introduced by him in the study area.
In the Bangalore district, not far from the Madanapalle study
area, in the longitudinal epidemological study done under
conditions with no antituberculosis measures at all being
' implemented, the estimated tuberculosis mortality during
1961-68 has been 100 per 100,000 persons (National Tuber
culosis Institute, loc- cit.)
It is realised that the quality of the above given mortality
statistics for India is very different and there must be some
regional variations as well. Nonetheless, the estimates if
plotted along a curve depicting the declining mortality in
Czechoslovakia since 1880 will show striking similarity of the
general trends (Radkovsky, loc. cit.'). In other words, the tuber
culosis epidemic in India perhaps has been following the same
course, some 30 to 40 years behind, as in Czechoslovakia at
least till 1950, when the era of potent antituberculosis drugs
began. Before coming to such a conclusion it would be wise
to guard against the possibility that the fall in tuberculosis
mortality was not largely or entirely due to a fall in the general
mortality. Ina way generally similar to that in Czechoslovakia
(Radkovsky, loc. cit.), the crude mortality in India also came
down from 47 per mille in 1911-21 to 15 per mille in 1971,
but the fall in tuberculosis mortality has been steeper i .e., falling
from about 17 per cent contribuiton to the general mortality
in 1920 to about 5 per cent now, comparing favourably with
that of Czechoslovakia namely from 15 per cent contribution
in 1900 to around 3 per cent in 1957.
In the opinion of many experienced clinicians in this
I country tuberculosis has undergone a considerable change in
I its clinical presentation, especially over the last quarter of a
' century. Many retrospective studies (Tuberculosis Associa
tion of India, 1958,1968) despite their scientific weakness have
clearly brought out the gradual change from a comparatively
more acute and extensive disease among the young to a more
chronic, less extensive disease among the elderly. The near
consensus of these reports has been on a marked decrease of
the concomitant complications of pulmonary tuberculosis, e.g.,
enteritis, laryngitis, amyloid disease, matted lymph glands with
discharging sinuses, etc. It is significant that very similar
changes were noticed in countries where tuberculosis has
definitely declined. The evidence in India, therefore, cannot
be brushed aside as unreliable.
decline of endemicity :
r; 1
V.
has been contended that the available direct epidemiological
information merely signifies no change in the prevalence of
bacillary tuberculosis in the country, at least for about 2 deca
des (Table 1). And, that equal prevalence in urban and rural
areas merely means that we are truly in the endemic phase of
the disease. It has also been argued that such a conclusion
would be in keeping with the long chequered history of India
where empires rose and fell like nine pins leading to wide and
repeated dispersal of the population and a good mixing of rural
and urban people (Tuberculosis Association of India, 1968).
It could be argued with equal force that poverty, malnutrition
and congested living, that have been with us for long, would
hardly favour the occurrence of conspicuous epidemiological
changes over 2 or 3 decades. And, that long range indirect
evidence in a chronic disease like tuberculosis cannot have
less validity than the direct but short range epidemiological
findings.
Table 1—Showing Prevalence of Tuberculosis per 1000 in
Various Epidemiological Surveys in India
Type of
disease
Survey period
National Madan- Delhi Tumkur Bangalore
survey
apalle
survey
survey
1962
1960-61 survey
1955-58 survey
1961-68
(ICMR, 1950-55 (Pamra,
(Raj
Narain (Nation
1959) (Frimodt- 1966)
Moller,
et al., al Tub
1960)
1963) erculosis
Institute,
1974) ’
Bacillary
Active
abacillary
Inactive
abacillary
Inactive
insignificant
4.1
4.0
18.0
4.0
4.1
13.2
14.9
4.1
10.6
27.5
9.1
Some direct evidence in favour of a declining trend, however,
has lately become available from the longitudinal epidemic- i
logical surveys. In Table 2, the Bangalore study (National |
Tuberculosis Institute, loc. cit.) is representative of the natural
time-trend of tuberculosis in a rural area whereas the Delhi I
study (Pamra et al., 1968) gives the position in a slum popu- ’
lation served by the New Delhi TB Centre providing treatment
to the diagnosed patients of the area. In both the studies
migration could have interfered with the findings, but the more
conspicuous and impressive effect of drought in the former
study suggests that migration may not have interfered much.
Of course, the observed decline in the already quoted Madana-j
pallelongitudinal survey (Frimodt-Moller, loc. cit.) was ascribed'
to the applied rigorous community control measures. Signi
ficantly, the decline observed in the infection as well as disease
rates in the Madanapalle rural TB control area and the Banga
lore natural time-trend rural area occurred first in the younger
age groups, as was to be expected. It would, therefore, be
reasonable to infer that there is a gradual but slow natural
Table 2—Showing Longitudinal Studies of Prevalence of
Pulmonary Tuberculosis in the Delhi and
Bangalore Areas
Delhi area
Prevalence per mille of
Abacillary
Sputum positive
Total cases
active cases
cases
1964
1967
Bangalore
area
12.9
13.7
Prevalence per mille of sputum positive cases
in age group (year)
All
15-34
35-54
>55
5-14
1962- 64
0-94
0.72
1964-66
1966-68
0.36
0.37
1961- 63
17.2
13.2
8.9
9.7
4.0
4.0
4.0
1962
3.77
3.59
3.04
2.58
6.16
5.25
6.04
7.56
11.46
4.06
12.08
10.10
12.19
3.72
3.37
3.93—
[ 3 ]
decline of tuberculosis in the country. That morbidity gets
easily disturbed by adverse conditions like severe malnutrition,
drought etc., may inadvertently lead to the impression that
tuberculosis is on the increase in the country or an area.
Apart from anything else, the “no change in prevalence”
argument favouring endemicity is not helped by the sizeable
I and rapid turn-over observed in the composition of prevalence
cases. Fifteen villages constituting a part of the sample of
NationalTuberculosis Survey, were resurveyed by the National
Tuberculosis Institute after 5 years of the first survey (Raj
Narain et al., 1962). The prevalence rates of radiological
disease were 1 -7 per cent and 1.8 per cent and of sputum positive
cases 0.36 per cent and 0.46 per cent respect ively in t he 2 surveys.
But, of the 26 bacillary cases of the 1st survey, 14 had died,
4 could not be contacted, 6 had either become sputum negative
or become x-ray normal/inactive and only 2 had maintained
the status quo at the time of the subsequent survey. The fresh
cases of the 2nd survey had come mostly from the x-ray normals
and some from x-ray abnormals of the 1st survey. Similar was
the experience from the longitudinal epidemiological study in
the Bangalore area. In other words, the considerable inci
dence of fresh disease is being marked by the sizeable selfhealing and deaths while in the endemic phase one would
expect low prevalence and incidence rates.
The available evidence strongly suggests that India already
has had more than one tuberculosis epidemics. At present we
are somewhere on the descending limb of the latest epidemic.
Grigg (loc- cit.) believes that the latest tuberculosis epidemic
in England began in the 16th century and in Europe a hunderd
years later. As in Eastern Europe, the latest tuberculosis
epidemic in India may also have begun in the 17th century.
The very slow or nil rate of decline is perhaps due to thB gene
rally unfavourable environment with personal privations and
or droughts causing temporary fluctuations in the seemingly
| stable prevalence.
ROLE OF TUBERCULOSIS CONTROL PROGRAMMES:
Can such a slow decline in the epidemic be hastened by
tuberculosis control programmes?
Environment is a fundamental factor in the ecological triad
of tuberculosis: Socio-economic conditions can alter the epi
demiological situation powerfully, for good or bad, over a
decade or two. Since BCG vaccination has no influence on
the naturally infected population and chemotherapy merely
eliminates some cases but cannot prevent cases from occurring,
a tuberculosis control programme has a low potential for
influencing the epidemic curve, over a short period. So far, |
no reported study has successfully demonstrated the prime
influence of antituberculosis programmes in controlling the
disease, without a concomitant marked improvement in the
standard of liivng of the people. But, control programmes
certainly help.
Under the National Tuberculosis Programme, infectious
cases of tuberculosis are being diagnosed at a comparatively
late stage. They, presumably, would already have done a
major part of the damage (spread of infection) that they are
capable of doing. Moreover, a sufficiently large number of
infectious cases (especially in the rural areas) has not so far
come under effective chemotherapy, as has happened in some
other countries or under study conditions. In the Madanapalle study area (Frimodt-Moller, loc- cit.) with control
measures applied vigorously it was after 2 decades that mor
bidity was reduced to less than half. The bacillus also possesses,
th.' power of mutation and under ineffective chemotherapy I
develops resistance to drugs quickly. Therefore, 2 crucial*
factors are needed before chemotherapy under the programme
could help reduce tuberculosis: A significant number of infec-^
tious patients brought under effective chemotherapy and a
couple of decades, if not more, of efficient effort. BCG
vaccination to be really useful must (i) be given correctly and
(ii) constantly cover a significant proprotion of the susceptibles
in the community. These requirements are difficult but not
impossible to meet.
Jt is only about a decade since our National Tuberculosis
Programme has been in operation, but not so effectively. With
the data available on the natural time-trend of tuberculosis i
and the operational study (Baily, 1972) of the average achieve-1
ments under the programme, a simple estimate of the expected •
contribution to control of tuberculosis has been prepared
(Table 3).
Of the average 776 truly sputum positive cases, including
drug sensitive and resitant cases, diagnosed and put on treat
ment in one year in an average district under the programme,
147 would probably be dead (in spite of treatment), 357 would
Table 3—.S
! howing Estimated Sputum Positive Cases in Average Indian District with and without District Tuberculosis
Programme at the End of One Year
Fate of prevalence cases during one year
No. of cases
at t0
(prevalence)
Dead
(sputum
negative)
Cured
(sputum
negative)
Remaining
(sputum
positive)
Without programme (natural
time-trend)
5,000
700
1,000
3,300
With programme :
Not diagnosed
4,224
590
845
2,789
Diagnosed
Total
776
5,000
147
737
357
1,202
272
3,061
Cases added
(incidence)
No. of cases
at tx
(prevalence)
1,700
5,000
1,700
4,761
[4]
become sputum negative—after applying differential cure rates
for the sensitive and resistant cases, and 272 would continue
to be sputum postiive after one year of chemotherapy. With
regard to the 4,224 undiagnosed cases in the community, the
death, cure and status quo rates would be the same as in the
uppermost row, as if there was no programme. This would
mean that 239 cases would be less in the community after one
year under the present efficiency of the programme. This
rough calculation without the other epidemiological “flows”
means a 4.8 per cent annual decrease, over and above the
natural decline, which need not be scoffed at. A corollary
I would be that dividends would be more if case-findings were
| to be improved in the programme, rather than treatment
results from the present 46 per cent sputum conversion at the
end of one year to say 80 or 90 per cent.
Summary
There arc reasons to believe that India has had more than
one epidemic of tuberculosis since the time of yore. The
present epidemic might have started in the 17th century. There
is evidence that the present epidemic has been declining since
the turn of the 20th century. The natural decline at present
is very slow, probably because of the prevailing poverty,
malnutrition and over crowding. The District Tuberculosis
Programme, even at the present level of efficiency, has a poten
tial of accelerating the natural decline. Improved programme
efficiency, especially under case-finding, is likely to produce a
quicker decline. Rapid socio-economic development and
improved standard of living could lead to a more spectacular
decline in tuberculosis, but that effort would not strictly fall
within the purview of a specific control programme.
References
Baily, G. V. J—An Operational Model of District Tuber
culosis Programmes, Paper Presented at the ICMR Sym
posium on Tuberculosis, Madras, 1972.
Frimodt-Moller, J—Bull. WHO,'ll-. 61, i960.
Grigg, E. N. R—Amer. Rev- Tuberc., 78: 151, 1968.
ICMR—Tuberculosis in India : A National Sample Survey,
1959, Indian Council of Medical Research, Special Report
Series, 34.
Lankaster, A.—Tuberculosis in India, 1920, Butterworths,
Calcutta.
McDougal, J. B.—Tuberculosis Global Study in Social
Pathology, 1949, Williams & Wilkins, Baltimore.
National Tuberculosis Institute—Bull-WHO, 51: 473, 1974.
Pamra, S. P., Goyal, S. S. and Mathur, G. P—Proceedings
of the XXIII Tuberculosis and Chest Diseases Workers’
Conference, Bombay, 1968, Tuberculosis Association of
India, New Delhi, p. 61.
Pamra, S. P__ Proceedings of the XXI Tuberculosis and Chest
Diseases Workers’Conference, Calcutta, 1966, Tuberculosis
Association of India, New Delhi, p. 91.
RadkoVsky, J—The Share of Tuberculosis in Total Mortality
in Czechoslovakia, 1888-1957, Working Paper, Inter
national Population Conference, 1959, Vienna.
Raj Narain, Geser, A., Jambunathan, M. V- and Subramaniam, M—Indian J. Tuberc-, 10: 85, 1963.
Raj Narain, Jambunathan, M. V- and Subramaniam, M—
Proceedings of XVIII Tuberculosis and Chest Diseases
Workers’ Conference, Bangalore, 1962, Tuberculosis
Association of India, New Delhi, p. 34.
Tuberculosis Association of India—Changes in the Clinical
Manifestation of Pulmonary Tuberculosis, 1958, Procee
dings of the XIV Tuberculosis and Chest Diseases Wor
kers’ Conference, Madras.
Idem—Symposium on Changing Trends in Tuberculosis, 1968,
Proceedings of the 23rd National Conference on TB and
Chest Diseases, Bombay.
J-’
IKK
e
Ind. J. Tub., 1993. 40, 99
BERCULOSIS PROGRAMME IN METROPOLITAN CITIES*
D.R. Nagpaui
ockj^e 7
lence rate revealed by NSS had per se very little
effect on the altered consciousness about the dis
said with justification that the Naease. It was obvious, then, that radical re-thinking
Survey (NSS)1 of 1955-1958 was a
and different planning approaches were needed to
ir perception of the problem of tumeet the challenge uncovered by the NSS.
idia. It changed the policies and
It could be argued that the almost equal prevad for its control, from the technical
2encc of tubcrculosis in urban and rural India, as
I appreciation of the realities of
revealed by a one-time survey, was accepted in
id acceptability of the measures
haste. Grigg’s monumental work "The Arcana of
ntrol programme.
Tuberculosis’” had evidence to show that urban
SS, tuberculosis was generally reand rural tuberculosis epidemics, in a country or
ian problem, concentrated mainly
area, could occur decades apart. If, coincidently,
o lived in slums or were poor and
the two epidemic curves intersected, the preva
ider-nutrition as well as malnutri- lence of urban and rural tuberculosis al that point
amme prepared by the Bhore of time would be same, after which the curves
ilth Survey & Development Corn
would diverge. The same could have happened
control of tuberculosis, therefore,
with NSS too. Apart from the fact that an aca
i of an urban
uiuan tuberculosis
luoercuiosis pro
demic argument should not encourage inaction, in
clinic for ]K)0,0CW
— population
........
(in the face of a chalk
iengc, the point was examined.4 It
) and a TB bed for each annual was hypothesized,
culosis. Beds for tuberculosis pa tuberculosis mt , on the basis of information on
ortahty in an European country and
ar away sanatoria, had waiting- the available data fn
./om India, that such could not
lly patients diagnosed in TB clin- be the case.
Nor have the several smaller surveys.
eir turn came for admission and done after the NSS,
, suggested otherwise, although
The other components of this
span of three decades elapsed since then is
BCG vaccination and rehabilita- relatively short5A7-8
special provision was made for
>, perhaps because the numerii- ~District Tuberculosis Programme
ed by them could lake care of
and advent of chemotherapy,
ed completely. As if overnight’
•
ia was seen as a rural problem.
.
3ople, living in villages, had no
them in the plan for receiving
ss. Besides, concentration of
elderly males made the stress
The challenge before the country was ad
dressed by the National Tuberculosis Institute
CiTDx Bangalore. Of a piece with the NSS, it
adopted the approach of operations research, and
not a priori planning, for reformulating the Na
tional Tuberculosis Programme (NTP). After
years_of sequential research, coupled with some
semniarsociologicarstudies, the outline of an epi-
garding periodic active
ne urban TB clinics by using
s sending into rural areas :
The precise disease preva-
gramme cmerped wkirh
_ correct pro
gramme emerged, which appeared practicable and
socially acceptable as well. That draft plan was put
p a| Ti.eS! RrUn ’ ’n AnantaPur district of Andfc
radph, before recommending it to government
X8ramnie- OrganiSed b* Foundadon for Research in
T'i
*
4
I
*
100
DR. NAGPAUL
TUBERCULOSIS PROGRAMME IN METROPOLITAN CITIES
as District Tuberculosis Programme (DTP).9 The
2. HeaW^^onsm^i^dtigs^ normally
DTP was; adopted as the basic unit of NTP in
1962.
It is a fundamental
I
principle of any operation
that rt
i is
' continually monitored and periodically would not be logical to invest still
in tl ---- -altered
- to
.J Iensure optimal functioning. The central
berculosis
monitoring done by NTI, and1 3
indcPendcnt have beenS programme,
fully uled" unless the existing facilities
assessments, have shown thal-DIPf have not'^- h■ ..
■ --Besides, private practitioners
m ernes arc a resource that needs to be utilized
3. While x-ray diagnosis has to continue, as before
“^ve actions, due to
mdrfferent admmistrauve support.’5 A technically the cpidemiologically more important sputum
positive infcctors should not get less priority, just
iTvitv TT"0? aS’ thuS' become a rout™ ac
nvity, as tuberculous control was before advent of because sputum examination is not ‘'fashionable"
m cities. AU smaller institutions and dispensaries
should provide sputum microscopy service.
4. Health institutions in cities have widely different
Tuberculosis Programme For Big Cities
affing Pancrns, equipment, technical standards
to,WOrk,ng comPlcle 'solation,
but^Tf
e'VCd “ a rural PWamme, dunii^'Ch
but one for an ayerageJndiandjsLrja, with a large theP.“!T-?.WOrk “d’ .conse<luenliy. waste of
the scarce resources. To bring all healih'^itu*
rural component of around 1.500 villages and
'i,lages..and qpto tions into
10 towns of which the district headquarters mav -...s into a single network, some of them may
need upgrading and others given flexibility of ac
- ..lousand people. It may have
tion. Expansion of the net work should
done
not meant to be a rural^rogranuiie.
only after very careful thought.
The decision to mak<
While presenting the outline, it
was stressed
sible for organising tuberculosis services dnd
the‘ wo^kl Phra,iOnr?S WC" 35 SOCiO,°8ical
'SPOn
would
be
needed
to
verify
the
assumptions
on
salutary principles underlying thc DTP had made
fluo^Th Urban.tubcrcu10^ programme super- which the plan was based, and provide the working
’ “ C°Uld bC lha‘ thc
fluous. Thc people, however, continued to think fo'r e ' h h
along separate lines, because the higher level of for each big city may look a little different
Smce 197(1, when the draft plan was pre
reason? T'1??'0 •" Urba" arCas’ for his‘o”cal
easons, called for, m their opinion, different kinds sented,13 no city based studies of the kind envisJl
aged appear to have been conducted. Thc votaries!
qualitatively nearer to city services, till the differenccs disappear. It becomes logical, therefore,
that those big cities which arc part of recognised
districts should implement DTP, with some suit
able modifications.
Case of Metropolitan Cities
The case of metropolitan cities, however,
stands on a different footing. Not only is a metro
politan city a big district in itself, which cannot be
further bifurcated but is amenable to formation of
zones/arcas, but the structure of its health services has a different character. Thc leadership role
in providing hcalth services is shouldered by the
municipal corporation, and not government. Besides, there is a plethora of organisations which
run these institutions, such as corporation, volun
tary organisations, government, health insurance
agencies and private trusts. All these organisations
have different objectives, organisational structure
and funding which require close working together,
constant dialogue, co-ordination and skilful per
sonal relations to succeed. Only the major partner
in the network could do all that. The government
should extend its full administrative"aliiTTogislic
support to the [>rogrammc. 11 becomes obvious,
then, that size of the population or the sophistication of the people, as well as nature of the available facilities are less crucial than the operational
environment in metropolitan cities. Of course, socio-behaviors I studies would still be needed to
measure how health conscious and knowledgeable
the people are and what kind of services they expect the city programme to provide. And. despite
good attempts made to organise metropolitan tuberculosis programmes, the tardy progress made
and multiple constraints faced underlines the need
for operational studies.
In 1975, NTI published a detailed plan for or
ganising tuberculosis programmes in big cities,
which is quite suitable for our metropolitician cit
ies.13 Il should be given a fair Irial, after locally
carried out studies have provided the working de
tails.
SbiX,“^0Tdp“p!,; 1'mayha'”r"-
b«
or £
^pTZ?hoS^
sophiMi- o?urbaa
-ices than those pX^feS
programme have also not '
organised the socially de
m . ..
manded belter tuberculosis services, as presumed
Text Book of Tuberculosis published by the Tu
berculosis
oerculosis Association
Association or.ndia" had'™
chapters, viz. Tuberculosis Control in RurafIndia clinics ’
J
sizeable proportion of TB
and Tuberculosis Control in Urban Areas despite work sr H
CVen leSS facililics and lowcr
[he sogaUaiM^kyolwai inpromoting.twodifc lo^ cenTr Th " aVailablC
dis‘rict ,ubcrcu^USSgramrucs
not nrn? i
C“y disPensari« which do
“Recognising the strong rural bias of DTP ami ch Pi- fC .,ubcrcu,os« services at all. And large
lhe different environment in very large cities (he colonies?
P°pu,atl0ns <slums and outreach
NTI prepared13 an -Outline of a Tuberculosis Pro- ^ne I T U"derserved
health services in
gramnie fa, Large
for widcr
and tuberculosis services in particular.
The salient features of this outline were:
’ cout
k
t*" br°U8hl Under DTP- ,hin8s
P',ogramrn‘: for large cities can not be outside
of NTP : While it could be somewhat different to
meet the different needs of the city people it has
n± x±imi'ar '° DTP 10
an integral
pan of NTP.
miegral
? ’l35 a’S0 t0
kcP' in
®en.eral hcalth services are con™provi‘,8- And sophisticated
through .hc'cf^S.
'hc grassroots
through the community health centres. Being an
integrated programme, DTP is bound to come
integrated
mind
stantlv h r
Health Senices Systems Research
i.
t-
However, at this point of time, it has become
necessary to keep in mind the crucial importance
of entire health services systems research, to meet
I
I___
101
thc hcalth needs of the people, and not deal with'
tuberculosis alone. Metaphorically speaking, NTP
as a system must sink or sail with the general
health services. In thc nineteen seventies, when
NTI found that DTPs were not performing as ex
pected, they found that operational studies into
general hcalth services were necessary, but were
unable to do so, administratively. It is desirable,
therefore, that in metropolitan cities, the entire
health services should be researched to formulate
an appropriate tuberculosis programme, with in
puts from NTI. While making such a plea, it may
be useful to stress a few points :
Operational Considerations
1. To pul structurally and budgetwise different
bodies into a single network, it is imperative to
recognise the independent existence of each insti
tution, in return for agreement from them not to
function in isolation.
2, One way for health institutions to give up isolationism is to involve them in evolving u work pat
tern which subordinates technology to the felt
needs of the people, and not the other way
around. as at present. A qualitatively different
approach to public health research is needed for
this purpose. The results should mean greater operational efficiency of programmes on account ol
their wider acceptability and reach.
3. Comparatively poor management-supervision,
staff training/rc-training, monitoring, decision
making and corrective actions have been the main
reason behind bclow-cxpectalion performance of
DTPs. Metropolitan cities, compared with dis
tricts, are rich in managerial competence : means
have to be found to harness this resource.
4. In some metropolitan cities, the area tuberculo
sis centres have appointed managerial teams to
oversee the operation, and got them trained at the
NTI on the lines of DTP. Their training should be
different, and the City Tuberculosis Officer should
have a team of somewhat different composition
under him.
Sociological Considerations
1. How do the city dwellers perceive the symptoms
suggestive of tuberculosis; what do they think is
needed for them, and what do they actually do,
and how much delay occurs before a source of
treatment is contacted and correct diagnosis iscslablLshed?
102
D R. NAGPAUL
2. How do the poor, middle and upper class city
people regard tuberculosis as a threat to their
health? What facilities would each class like to
avail of, if some one in their family had the dis
ease, and what problems are likely to arise, includ
ing expenses, transportation, co-operation from
the family and pressures from society?
3. Since motivation by health institutions’ staff has
repeatedly been shown to be insufficient, to en
sure satisfactory completion of treatment, behav
ior studies are needed to suggest an optimal sys
tem of drug distribution which could remove this
weakness.
In summary, it is patently clear why the pre
dominantly rural average Indian district received
greater attention under the NTP than large cities.
Also, why the DTP, as the basic unit of NTP, has
not performed upto the expectations, on account
of management weaknesses and not technological
shortcomings. It has been shown why it is not nec
essary to think in terms of separate rural and ur
ban tuberculosis services. The manner in which
the existing tuberculosis services in most big cities
can and should be made a part of DTP/NTP has
been discussed. In metropolitan cities, where the
operational environment is different, the prin
ciples of NTP can still be applied, after due opera
tional and sociological studies, but it is preferable
if such studies are made a part of overall Health
Services Systems Research.
References
K-MR : Tuberculosis in India-A Sample Survey,
1955-58; Special Report Series No. 34.
2. Government of India : Report of the Health Sur
vey and Development Committee; 1946.
3. Grigg E.R.N. : The Arcana of Tuberculosis; Am.
Rev. Tub.', 1958, 78, 151.
4. Nagpaul D.R. : Tuberculosis in India-A Prospec
tive; Jour. Ind. Med. Assoc.; 1978, 44, 48.
5. Raj Narain, et al: Tuberculosis Prevalence Survey
in Tumkur District; Ind. J. Tuber.; 1963. 10, 85.
6. National Tuberculosis Institute : A five year
epidemiological study : Bull. IVld. Hlth. Org.; 1974,
51, 473.
7. Goyal S.S., et al : Tuberculosis trends in an urban
community; Ind. J. Tuber.; 1978, 25. 77.
8. Gothi G.D., el al ; Prevalence of tuberculosis in a
south Indian district-Twelvc years after initial sur
vey; Ind. J. Tuber.. 1979, 26, 121.
9. Nagpaul D.R. : District Tuberculosis Control Pro
gramme in concept and outline; Ind. J. Tuber.;
1967, 14. 186.
10. Nagpaul D.R. : India’s National Tuberculosis Programmc-an Overview; Ind. J. Tuber.; 1989, 36, 205.
11. Tuberculosis Association of India : Text Book of
Tuberculosis-Second Revised Edition, Vikas Pub
lishing House Pvt Ltd, 1981.
12. National Tuberculosis Institute ; Outline of a tu
berculosis programme for large cities; Paper pre
sented at the 25th Tuberculosis and Chest Dis
eases Workers' Conference : Patiala, 1970.
13. Nagpaul D.R. : A Tuberculosis Programme For.
Big Cities; Ind. J. Tuber.; 1975, 22, 96.
?
to
I
Contemporary Issues
Ind. J. Tub.. 1993. 40. 103
gabad brought out the fact that the public health
services alone - whether run by the government or
SYMPOSIUM ON URBAN
municipal corporations - have not been able to
TUBERCULOSIS CONTROL
properly tackle the problem of tuberculosis. And, it
is the social, operational, economic and managerial
rather than the technological constraints which have
The National Tuberculosis Programme (NTP) hampered the effective implementation oflubcrcuwhilc spelling out the steps to be taken for tubercu losis control services in urban areas.
A multitude of health services already exist in
losis control in rural areas, where the majority of
population lives, assumed that cities already having most of the cities. And, unlike in rural areas, access
the infrastructure to tackle the problem needed no to health care services is rarely a problem. Under
specific inputs. Urban tuberculosis control has, the DTP, while health services for tuberculosis
consc
uviiu received modest
- attention from both control are offered to the people largely by the
consequently,
plannerTand ‘rwcarchersTn‘order to discuss the public health services, several studies have shown
[
1
-------various issues involved in urban •tuberculosis
con-. that people themselves prefer the services ottered
l’rol7ha7e cxperiences’ofthc people working in this by non-governmental organizations : voluntary
area and also (o discuss alternative strategies and1 agencies and the private doctors. No city tubercuiointerventions for effective urban tuberculosis con sis programme has succeeded in effectively involv• • ’ini Bombay
on the 26lh ing these preferred providers of health services to
trol, a symposium was ■held
I
(he people in controlling tuberculosis,
tuberculosis.
and 27th of September. 1992. The symposium was the
organised by the Foundation for Research in ComPresentations on projects run by voluntary or
munity Health, Bombay, a non-governmental re ganizations and groups of private medical practitio
search organisation which has been involved in ners working in urban areas offered some thoughtsocial anu
and upciauuiiai
operational ivovui*-..
research ...
in ...W
the area of
tuber- .....
ful solutions to the .present .pr
Social
—----culosis control, and sponsored by the International tcred in organising tuberculosis^ control >
Development Research Centre (IDRC), Canada. areas. These agencies seem to have effectively
The participants in the symposium comprised na employed innovative approaches that need to be
tional experts in (he field, programme managers studied further for replicability. The various ap
from government and municipal bodies, represen proaches included : provision of well co-ordinated
tatives from several non-governmental organiza mobile anli-TB services, as applied by the Cheshire
.... researchers.
....
Home in New Delhi; having a special component
tions, private practitioners„ and
Following is a summaary of the discussions that offering diagnostic and treatment services for pa
tients referred by private doctors in return for using
took place during the course of the symposium :
While the concept of DTP holds true for a geo their proximity to the patients for ensuring compli
graphic area, urban and rural, its meaningful appli ance. as done by the Maharashtra Lokhita Seva
cation to large cities remains to be demonstrated Mandal; a loose networking of private doctors,
even after 3 decades of its operation. Since the each of them providing treatment services to their
implementation ol the DTP. which has a strong patients, with records and reports maintained at a
rural bias, there has been a 175% increase in the central place, as being operated by the Ashwinikumar
urban population. This rapid urbanization has given Medical Relief Trust in Bombay, and a group of
rise to slums and shanty towns in many cities. The private practitioners belongmg to the medtcal assopoor socio-economic and environmental conditions ciation of a municipal wardoffermgservrcesthrough
-■
;;
a common treatment centre. Compared with the
in which these populations live make them
a highdeserve performance of public health providers, these ap
risk group. And these slum populations
[ .
proportionately greater inputs from the programme. proaches seem to Ik yielding desirable treatment
Viewed against (his background, tuberculosis con completion rates, to the tunc of 80 per cent. This
trol in the big and growing cities also deserves could be the outcome of a belter provider-user
rapport, compared with l hat offered by public health
special consideration within the DTP.
Presentations on the status of TB control pro agencies.
It would appear that the solution to effective
grammes in big and growing cities including Delhi,
Bombay. Bangalore. Hyderabad. Pune and Auran- urban tuberculosis control may lie in incorporating
Ind. J. Tub .. 1993, 40, 105
CONTEMPORARY ISSUES
104
FORUM
different provider bodies in "area networks", with small scale experiments in some urban areas and
the public health system not "controlling" these adapting the successful elements within the NTP.
agencies, but providing them central support, moni- The city of Bombay provides excellent opportunitoring and training components. It must be empha- tics to lake up such studies.
sized, though, that the success of such a networking
will depend heavily on the consideration given not
Dr Shccla Rangan,
only to people's perceptions and their fell needs Senior Research Officer,
areas which need careful research - but also to Foundation for Research in Commuinty Health (FRCH),
maintaining individual identities of provider bodies.
84-A, H.G. Thadani Marg,
A good beginning could be made by undertaking
Bombay-400 018.
»
DR.M.0. DESHMUKH
Sir,
1 am a subscriber of your esteemed Journal for
Dr. M.D. Dcshmukh, the grand old man of tuthe past eight years. I have greatly appreciated the
and chest diseases, doyen of the tubercupragmatic approach of the Journal on the problems losis workcrs and a multi-splcndoured personality is
affecting the National Tuberculosis Programme. no morc He died on25th January, 1993 at the age
The bottlenecks, however, continue to persist even of
Fcw havc achiCved excellence in so many
after three decades. It is not easy to appreciate why spheres. Hc was a brilliant academician, a gifted
something is not being done about these problems. teacher, a prolific writer and a sound research
You recently touched on the problem of the worker.
National Drug Policy (April, 1992, Editorial). It
Having graduated from the Grant Medical Colencouraged us all very much and we were expecting
Bon^bay and awarded M.R.C.P. from London,
something constructive to be done by the office of hc
ass'an army medical
- •----...
specialist during the
Drug Controllers, both at the centre and in the second
s
world war and as a teacher in Wales (U.K.)
stales, but in vain. You are probably aware that jfrom 1947 to 1952. On reluming lo India, he was apthere is complete anarchy in the marketing of drugs poin[ejas Honv.TB Specialist at the Grant Medical
in this country. There are over OO.IXX) formulations Collegc and sir J.J. Group of Hospitals, Bombay
of drugs and the multi-nationals as well as the Indian whcr£ h£ taugh[ for 20 years. During this time he
drug manufacturers pay little heed to the demands was cxamjner and inspector of examinations in tuofthe All India Drug Action Network (of the Volun- bcrculosis in many medical coUeges, all over the
tarv Health Association of India) and the Drug coun(ry. Always interested in research, he had over
Action Forum (of West Bengal). Unscientific com- KM) scient
' ific papers to his
....
r which
----------------credit, of
the most
binations, anabolic steroids, thousands of cough noteworthy work was on Isoniazid Chemoprophy
formulations that arc not even recognised in the laxis and on Tuberculosis complicated with Diabe
standardlext-booksand Pharmacopoeia.cyprohep- tes. He presented technical rpapers
,
on Tuberculosis
tadines as appetisers for children along with vita- jn many internationai and national conferences,
mins under numerous names arc being prescribed
was g piu^ of slrength to the MaharashUa
indiscriminately both by the qualified practitioners S[ate JB AssociutiOn. since 1962, where his most
and the quacks. The multi-nationals practise double remarka|qc work was the pioneering services of
standards in third world countries. Could you kindly anli.TB shibirs for rural areas.
focus on this burning problem in one of your future
He was closely associated with the Tuberculosis
Association of India for many years and was a
issues?
Dr. S.K. Basu member of all its important Committees viz. Cen
Bankura. tral Committee, Executive Committee andTcchmWest Bengal, ^‘committee.’Co-Editor of the IndtAD Journal of
ERRATA
In the January 1993 issue of the Indian Journal of Tuberculosis,
Para
Instead of
1
1
21-0 age group
21-50 age group
1
2
446 (8.7%)
14
1
2
314 (41.3%)
14
1
3
446
14
1
3
(87.9%)
14
1
14
2
3
2
314
14
2
2
18 (0.3%)
15
1
1
314
456 (60.0%)
304 (40.0%)
456
(86.0%)
15
304
158 (52.0%)
304
39
1
1
Since these stages
arc not considered
as phases of the
disease, the condition
inevitably progress to
fibrotic lung.
Page
Column
14
14
1
Read
These stages are not
considered as phases
which inevitably
progress to fibrotic
lung.
NEWS AND NOTES
I
1
'r
In recent months the Editor had to
return several otherwise suitable
manuscripts to their authors since the
accompanying photographs/X-rays were
not suitable for reproduction. We would
request all prospective contributors
to pay special attention to the quality
of the films while submitting their
manuscripts.
Tuberculosis and co-author of the Text Book on
Tuberculosis published by the Tuberculosis Asso
ciation of India. He presided over the 20th All-India
TB Conference, at Ahmedabad in 1965.1ft recogni
tion of his services to the anti-JB movement, the
Tuberculosis Association of India awarded him its
Gold Medal in 1974.
His demise is a great loss to the country, the
medical profession, the Tuberculosis Association of
India, the Maharashtra State Anli-TB Association
and all those who came in contact with him. The void
left by him will be extremely difficult, if not impos
sible, to fill.
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