|EVALUATING CONTROL PROGRAMMES
|J O'Rourke:Proceed 19th Natl TB & Chest Dis
Workers Conf, New Delhi, 1964, 195 208 & Indian J TB 1965, 12,
Control of tuberculosis may be defined as
a deliberate interference in the relationship between man and bacillus
that changes favourably the epidemiological trend. Compared with
the other factors at play on this relationship, the weapons available
for a control programme are narrow in their range and must be used
with great foresight if they are to benefit the country. Under Indian
conditions, with tuberculosis ubiquitous in its occurrence, with
no striking focality of infection and disease that would justify
selective restricted efforts, control measures must necessarily
cover the whole community and the programme must be maintained for
a long time. Control will be a slow process, demanding continued
investment of men and supplies, persistent and careful organisation.
There is no short cut.
The assessment of programme (performance)
requires similar approach. Evaluation (impact) must concern
itself initially with examining the operational and technical performance,
enquiring in detail how the immediate achievement has compared with
the forecast, as changes in prevalence are expensive to detect and
may not be due to control measures applied. In general, supervision
asks if a rule is obeyed: assessment enquires whether it
has really been obeyed, whether it can and should be obeyed and
whether there might be a better rule. For e.g. evaluation of BCG
campaign encompasses the whole series of activities undertaken and
not only confined to occasional surveys of post-vaccination allergy.
It is important for curative work also. Pilot evaluation report
of Anantapur programme after one year in 1962 is given as an example
of simple assessment. A great majority of patients diagnosed at
district centre came from outside, while at peripheral hospitals
90% came from the same taluk. Treatment completion were 38% to 40%
among patients belonging to the same town and very low among those
living outside. This gives importance of Case-finding in peripheral
centres. Referral also played very little part. The accuracy of
diagnosis, proportion of cases diagnosed, number completed treatment
and rendered negative, are included in the assessment. Besides these,
cost of the programme and expansion of the programme to the
whole district, accuracy of the case index, operational achievements
at individual centre/district, prevalence of initial drug resistance
among clinic patients, should also be considered. Even such an elementary
evaluation demands careful organization and clear procedures: staff
must be allotted and trained for the purpose and equipment
must be provided. The assessment must be objective and independent:
it seems appropriate that the procedures would be undertaken, in
each state, by staff from the State Tuberculosis Centre, Regional
Offices under the Union Government could also be involved. The responsible
centres must have portable, hand operated punching equipment and
facilities for sputum culture. If tuberculosis in India is to be
controlled by human intervention and health to be effectively promoted,
independent assessment of programmes, feeding back into research
so that problems will be solved and the solutions timely applied,
is absolutely essential. As yet, both methodology and the organisation
needed are embryonic and demand therefore particular attention and
priority. Administrators and scientists alike face, in nurturing
evaluation, an unusually difficult and promising challenge. Recognising
and accepting a challenge is in itself an important development.
|KEY WORDS: CONTROL PROGRAMME, EVALUATION, ASSESSMENT.
|ASSESSMENT AND MONITORING OF NATIONAL TUBERCULOSIS
|SS Nair: Indian J TB 1971, 18, 131-34.
Assessment of a programme is the measurement of
the extent to which its objectives have been fulfilled. This may
be called assessment of efficacy. For this the objectives
have to be defined in quantifiable terms i.e., the extent and period
of time problem of tuberculosis will be reduced. This is yet to
be done for the National Tuberculosis Programme (NTP). Assessment,
of efficacy is difficult as the impact of Tuberculosis Programme
is felt only after a fairly long period of time during which other
socio-economic factors etc., also influence the problem. Any early
assessment of problem reduction will only be a very costly attempt
at proving the obvious and will possibly lead to frustration. Hence,
a different methodology of assessment has to be adopted.
Assessment of Efficiency: Measurement of the extent
to which the expectations for various activities under the programme
are being fulfilled is referred to as assessment of efficiency.
This seems to be a practicable solution to the problem of assessment
of NTP. Realistic expectations for output and coverages under
different activities can be set up on the basis of potentials on
one hand and performance of programmes with reasonable efficiency
on the other. Achievements of the programme could then be matched
against these expectations. There is a need to define stages of
programmes as different districts will have the programmes developed
to different levels. Any overall assessment of such a heterogeneous
programme situation may give a confusing picture. Advantages of
this method are; i) number of districts which qualify to do from
one stage to other will itself indicate the progress achieved; ii)
after assessment attention can be concentrated on the corrective
actions required. A detailed stage by stage assessment could
be supplemented by monitoring i.e., a continuous watch on
some key indices of the programme calculated from the periodic reports.
This requires reasonably efficient reporting machinery. The key
indices are: i) achievement of activities: Case-finding, treatment
completion and BCG vaccinations against the expectations; ii) contribution
from Peripheral Health Institutions; iii) No. of cases diagnosed
against the prevalence of cases in the district.
Assessment should be objective enough to inspire
confidence and its findings should be accepted or at least appreciated
by the persons in-charge of the actual functioning of the programmes.
For this, a proper climate for assessment should be created so that
assessment is welcomed by programme organisers and corrective actions
are taken soon after completion of assessment.
|KEY WORDS: ASSESSMENT, MONITORING CONTROL PROGRAMME.
|DETERMINATION OF APPROPRIATE INDEX AND TIME FOR
ASSESSING THE EFFECTIVENESS OF TUBERCULOSIS CONTROL PROGRAMME
|SS Nair: Indian J TB 1977, 24, 58-61
The present definition of the objectives
of the National Tuberculosis Programme is too vague. A proper definition
of the objectives, both longterm and intermediate, is needed. It
should clearly state the index to be used for measurement
of the problem and the expected values of this index at specific
points of time. Another serious problem in assessment is to find
out how much of the observed problem reduction is due to the
impact of the programme and how much due to (or in spite of)
the natural trend (downward or upward). Repeated surveys
cannot provide this information and keeping of control groups is
not feasible. Epidemetric models help in choosing the index
for measuring the problem and fixing intermediate and long term
objectives in terms of this index. They also help to take the natural
trend into account, while assessing the programme.
Prevalence of infection is the least sensitive
index. Prevalence of disease and incidence of infection may lead
to over optimism. Incidence of disease is most suitable but difficult
to get in developing countries. Hence, prevalence of infection or
disease has to be chosen. Difficulties of the former are interference
by BCG vaccination and non- specific sensitivity. The use of BCG
induration to estimate prevalence of infection has some advantages
and it is worthwhile to investigate further this possibility. Using
epidemetric models, two methods of assessment of effectiveness
are suggested. One to carry out prevalence surveys but need
not be attempted unless programme efficiency has been quite high
for at least 10 years. The other is the assessment of efficiency
of the programme which can be easily carried out.
|KEY WORDS: EPIDEMETRIC MODEL, CONTROL PROGRAMME,
ASSESSMENT, EFFECTIVENESS, EFFICENCY.
|A SIMPLE MODEL FOR PLANNING AND ASSESSMENT OF PROGRAMMES
FOR TUBERCULOSIS CONTROL
|SS Nair: Indian J Public Health 1977, 21, 111-31.
BCG vaccination (prevention) and Case-finding followed
by treatment (cure) are two universally accepted methods for controlling
tuberculosis. BCG trials in selected populations have provided some
information on the protective value of BCG, generally over short
periods of time (below 20 years) and mainly among younger populations.
Efficacy of different drug regimens for treatment of tuberculosis
are well established and a number of studies on the effectiveness
of different types of treatment programmes on the patient population
are available. However, the manner in which BCG and treatment affect
the four epidemiological indices of prevalence & incidence of
infection and prevalence & incidence of disease in the community,
over a period of time, has not been reported in detail.
This paper describes a simple set of models which
can be used to predict the trend from these indices under
different types of TB programmes (including no programme) which
can be depicted as a combination of 5 programme parameters. How
these models can be used for planning and assessment of programmes
have been demonstrated by some examples. The trend in the incidence
of disease obtained from this model is similar to that reported
by Waaler et al in 1974. Unlike earlier models, the present model
starts with cases and the calculations involved are simple enough
to be handled by calculators and computer facilities are not necessary.
|KEY WORDS: MODEL, PLANNING, ASSESSMENT, CONTROL