appropriate retraining if required. Technical operational corrective action should be taken by the general supervisor there and then, during his supervisory visit. Provision should, however, be made for timely and selected corrective action by the appropriate officer at the intermediate level.
･Care should be taken that the overall quantity of work assigned to each multipurpose worker is reasonable. If additional help is needed, appointment of another multipurpose worker is preferable to posting a separate tuberculosis worker, as is sometimes done.
Most of the difficulties that arise in the integrated tuberculosis programs are due to neglect or imperfect fulfillment of some of or all of the above conditions6.
3.2 Three elements of successful integration of tuberculosis control into PHC.
The PHC concept has been widely accepted7. Nearly three-quarters of developing countries have national plans indicating how extension and re-orientation of the existing health infrastructure will be undertaken to achieve the goals of PHC. However, progress in implementation has been slow. In this situation to successfully integrate tuberculosis control into PHC the following three elements are needed:
A. Each government needs to take responsibility in establishing the PHC infrastructure. In addition to the establishment of this infrastructure, funding and sound policies to support the function of PHC is essential. Governments must be financially committed to long-term TB control programs.
The infrastructure needs to include the following three levels:
･The Peripheral Level: On average this level services between 1000 and 2000 people, has at least one multipurpose health worker, access to essential medications, and an established unit.
･The Secondary Level: This level has a considerably higher standard of qualification. It embodies a health center, a number of professional health workers, is actually a multipurpose health center, and works in cooperation with the surrounding community.
･District Level: Despite its changing definition in the various countries of the world, the district is the fundamental geographical, administrative and technical entity from which health action can be managed, and the PHC as well as tuberculosis control activities can be planned and supported, The district, serving an average population of 50,000 to 300,000, sometimes surpassing half a million, includes one hospital and several health centers scattered over the district territory and usually accessible to the population in less than a day's travel.
In addition to funding, governmental policies must emphasis the involvement and understanding of tuberculosis control of each individual in the various levels of profession. If the professional doctor doesn't understand their personal involvement in tuberculosis control it will quickly become burdensome and neglected.
B. Provincial and District levels must have a fully functional "monitoring center" for Tuberculosis Control Activities. The monitoring facility's must include a TB microscopy laboratory, reporting, registration, and patient file notification area, and a monitoring room for patients. The monitoring center must be located according to its availability, it may be "integrated" on the hospital premises8 or on those of the district reference health center, which is usually situated in the main population cluster of the district.
The managers in these two levels must be specially trained, well knowledged, experienced, and possess good management skills, and have experience in community work. A precise understanding of NTP and its implementation is an essential element for the manager. The result of the manager's work will determine the success of the integration of TB control into the PHC program9.
C. Support Measure for the National Tuberculosis Control Program.
The integration of TB control into the PHC should focus on the intermediate and district levels. However, it is necessary to acquire support measures from the NTP. These measure are:
･Standardization of diagnosis and treatment procedures
･Standardized system of the patient information and registers
･Management of treatment failure, relapses, and complications at the provincial level
･Regular supply of drugs and laboratory agents
･A quality control system in laboratories
･Training and refresher courses organized at the national level and/or provincial level
･Regular supervision and evaluation from outside the province and district
3.3 Tuberculosis Control Activities in PHC
The three activities are applied within the PHC: BCG vaccination of children, case-finding among persons with chronic cough, and directly observed treatment short course for smear positive cases.
A. BCG vaccination.
BCG vaccination is managed by teams responsible for implementing the Expanded Program of Immunization (EPI).
B. Case-finding.
All adults attending the health units, or met at home visits, should be questioned for the presence of the following symptoms: cough, expectoration, haemoptysis, fever, chest pain, and loss of weight and last for more than two to three weeks. If such symptoms are present, the person is asked to produce two sputum specimens, one on the spot, the other the following morning. The person should be instructed how to produce sputum and not simply saliva.
For the examination of the sputum there are three alternatives:
a) To send the sputum to the nearest place where microscopy can be done. The name of the patient should be written on the outside of the container. If there is no refrigerator, the sputum should be sent the same day it is collected. If there is a refrigerator, it can be kept up to seven days, which facilitates shipment.
b) To send the sputum smeared and heat fixed on slides. This procedure facilitates the storage and transport of samples to the microscopy center where the slides will be stained and read. However, each requires a great effort in training PHC workers in the method of smearing and fixing slides, and logistic problems of maintaining a regular supply and materials.
c) Refer the patient to the nearest location where diagnosis can be performed.
In the area where chest radiograph is also used in case-finding, every effort should be made to have the diagnosis of TB confirmed bacteriaologically so that overdiagnosis is avoided.
The training of PHC workers in TB case-findings includes these operations:
･General education of the public on TB, the signs and symptoms and the availability of effective treatment.
･Obtaining information on symptomatics;
･Instructing the patient on how to provide sputum specimens and supervising the procedures;
･Sending sputum specimens to the microscopy center (or smearing and heat fixing slides to be sent to the microscopy center)
