INTEGRATION OF TUBERCULOSIS CONTROL INTO PRIMARY HEALTH CARE
by
Dr Wang Jie-Xiu
Director Tianjin Tuberulosis Center
Tianjin, China
1. INTRODUCTION:
The current World Health Organization (WHO) policy on tuberculosis control was formulated nearly two decade ago, in the eighth report of the WHO Expert Committee on Tuberculosis1 and reaffirmed and enlarged in the ninth report in 19742. In 1981, IUAT in cooperation with WHO formed a study group to re-examine the Tuberculosis Control Strategy outlined in the ninth report. Their findings concluded that the main concepts in the Tuberculosis Control Strategy were both sound and valid. The case-finding/treatment complex has been further strengthened by the use of high efficacy of short-course chemotherapeutic regimen. The Study Group considered the newly developed strategy of Primary Health Care (PHC) as offering major new operational opportunities. The Group was also convinced of the necessity of attempting to implement TB control measures through the PHC systems. Integration of case finding and treatment within this system is likely to benefit the control program3.
To review the practicability of TB control technology at the different PHC levels and to advise on technical as well as operational problems in the integration process, a consultation was held by the World Health Organization in Geneva from September 22nd to 26th 1986. The meeting brought together experts in TB and in primary health care. Although the experts could not produce a universal blueprint for the integration of TB control, they tackled the key issues and proposed many solutions in the true spirit of PHC. The ideas they raised deserve attentive observation by all organizers of PHC programs and administrators of national TB programs4.
2. THE CONCEPT OF TUBERCULOSIS CONTROL AS AN INTEGRAL PART OF PRIMARY HEALTH CARE:
Almost all developing countries attempting to provide health services for their populations have had to rely on limited resources, including funds, facilities and training personnel, to cope with a vast unmet demand for health care for a variety of serious health problems. In most cases the response to this dilemma has been the establishment of special programs aimed at specific diseases and conditions. Thus, there came into being a set of vertical single-purpose programs each with a virtually independent infrastructure responsible for its planning, staffing, supplies, and evaluations. These programs competed with each other, as well as with any existing system catering to the treatment of common illness, for scarce local and extemal resources. All failed to satisfy the need of the population as a whole, often even in the short time. Recognition that this fragmented approach was both wasteful of resources and relatively unproductive came gradually and at a different pace in each country.
In May 1977 the WHO approved the 30, 43 resolution of, "Health for all by the year 2000." Between September 6-12, 1978 delegates from 134 countries and 64 delegates from special agencies in cooperation with WHO, UNICEF, and NGO participated in the International Conference on Primary Health Care at Alma-Ata, USSR. During the conference an innovative approach was put forward under the term primary health care, and officially adopted by all governments.
The PHC envisages the provision of the health care facilities to all parts of a country, offering equity in health care for every member of the community, as well as active involvement and participation of the community in health care programs through the activities of individuals, of families and of the community collectively5. The community health worker, whose importance in the health care system is increasingly recognized, provides a link between the health services and the community and could be expected to play a significant role in tuberculosis control.
The PHC approach, as embodied in the Declaration of Alma-Ata, recognizes the basic right to health care for each individual and rest on the principle of equitable use of health resources, especially with regard to the coverage and effectiveness of health care. Its basic requirements are:
･that there should be total coverage of the population with basic but essential health care, particular attention being given to needy, vulnerable groups;
･that services should focus on the major health problems of the population, should be affordable, and should employ technologies that are locally appropriate as well as acceptable;
･that communities should participate actively in the planning, implementation, and evaluation of health services; and
･that services should coordinate with other sectors involved in development, since progress in health leads to, and at the same time depends on, socioeconomic progress.
Integrating TB control into a PHC system was initially expected to be an easy task, given the availability of relatively simple technology, capable of gradual implementation, that could seemingly be applied in almost any setting. Since then it has been realized that good health management is as critical for success as sound health technology, and that managerial skills merit increasing priority in developing countries. Managerial weaknesses have become particularly evident at the intermediate or district levels where, as countries expand their health services, decision-making and support structures must be built up. It is now obvious that the PHC approach cannot rely on central planning and management alone. District-level health planing and management is needed to deal rationally with the organizational requirements of these geographically defined areas.
3. INTEGRATION OF TUBERCULOSIS CONTROL INTO PRIMARY HEALTH CARE:
3.1 Conditions for the Success of Integrated Programs
Conditions for the success of integrated tuberculosis control programs include the following:
･Integration should be effected at all levels of the health service not merely at the periphery.
･Integration should be structural and functional as well as attitudinal; it should not be merely a bringing together of two types of health worker under one program or in one health institute, with each type assigned different duties.
･Integration should be carefully planned, and implemented in a gradual and phased manner, by health staff who have been methodically trained. Integration does not consist only of issuing administrative orders. The orders must be followed by setting up the appropriate organization, by motivating the workers to accept integration, and by adapting their duties for efficient operation of the new plans.
･All the general health institutions, irrespective of their size, location, and facilities, should help to implement the program in order to provide the people with full and free access to the tuberculosis services.
･Manuals defining an explaining the simplified and standardized program procedures should be distributed to general health workers for their day to day guidance, in addition to the training courses that should be provided for them. All professional and auxiliary staff should accept in a willing spirit the multipurpose duties that will fall to their share as a consequence of integration.
･Close technical as well as operation supervision of the work in each health institution is necessary, for early correction of the errors and for institution of
