K Chaudhuri, MS Krishna Murthy, AN Shashidhara, R Channabasavaiah, TR Sreenivas & AK Chakraborty: Indian J TB 1991, 38, 131-37.

A study was conducted in 1983-84 by the National TB Institute (NTI) in the districts of Dharmapuri (Tamil Nadu) & Ananthapur (Andhra Pradesh). Thirteen health personnel were trained in census taking, tuberculin testing & reading and data keeping etc., at the NTI according to the standard methodology. The trainees were repeatedly assessed and only those who achieved a reasonably high inter-reader correlation with the standard reader were chosen for the field work. Field work was carried out by these health workers and supervised by the team leaders of NTI. Children between 0-9 years were tested with 1 TU RT 23 with Tween 80 in tuberculin testing centres specially set up in each village and the reactions were read between 48 & 72 hours after the test. The tuberculin testing/reading coverage was very high. Of 6702 eligible children, 5904 (97%) were tuberculin test read.

Individual reading assessment carried out at Ananthapur and Dharmapuri for the State Field Workers (SFWs) showed that agreement with Standard Reader (SR) of NTI at three induration levels i.e., 10+ mm, 14+ mm and 18+ mm were very high. The demarcation line between infected and uninfected appeared to be about 18 mm. In Ananthapur, the agreement at 18+ mm was 99% and at Dharmapuri it was 100% for SFW, and 98.4% for SFW-2. The estimates of prevalence rate of infection were 9.3% - SFW V/s 9.7% - SR at Anantapur, 5.2% - SFW V/s 5.2% - SR and 7.2% - SFW.2 V/s 7.2% - SR at Dharmapuri. The study further showed that it was possible to train general health workers, within a period of 3 months to attain a high level of efficiency. The general health services can successfully organise on their own a programme of tuberculin testing in the community with proper liaison and supervision by some nodal agency. The training and field supervision responsibilities may be shouldered initially by NTI or another suitable organisation, till these nodal agencies come up.


D Banerji: Indian Practitioner 1964, 17, 137-43.

In this paper an attempt is made to examine how the data from the history of medicine in India can help in formulating health programmes that deal with health problem as an integral part of the overall causation. India’s 5000 years old history provides an enormous perspective of the nature of man’s struggle against his environment starting from Indus Valley Civilization, the influence of Vedic Way of life of Buddhism, followed by frequent foreign invasions and general decline in the living standards of people. At the time of independence in 1947, India faced on one side, staggering problem of poverty, hunger, illiteracy, size in population and on the other side advantage of having ready made technological knowledge which could create effective weapons for dealing these problems. An Ecological Analysis of the History of Medicine in India shows an expansion of population due to availability of abundant resources which meant an increase in prosperity and social development. Public health facilities of the city of Mohenjodaro were superior to all other communities of the ancient orient. Almost all households had bathrooms, latrines, often water closets and carefully built well indicating the extent of health consciousness of ancient Indian people. During Ashokan period, there is existence of social medicine along the line of Buddhist Ideology. Emperor Ashoka states that “all over his dominions and adjoining territories, medical treatment is provided for men and animals”. However, the radical changes that followed after the introduction of British rule dealt a fatal blow to the practice of the Indian System of Medicine. A shift to practical western medicine during Nineteenth and Twentieth centuries led to neglect of Indian medicine and further decline.

These historical data help in providing a better understanding of the genesis of the present situation are also of immense importance for forecasting the pattern of health problems and health practices in the context of ecological changes that are expected to be brought about by other social development programmes, e.g., mechanisation of coal mining might influence the epidemiology of ankylostomiasis through better standard of living; conversely effective ankylostomiasis programme may bring prosperity by increasing the productivity of the coal miners. This is known as Positive Circular cumulative causation phenomenon-. To-day, Indian society stands on the threshold of far reaching social, cultural and economic changes. Utilization of the scientific knowledge generated by Industrial Revolution for dealing with health problem is essential for practicing modern medicine. A sound of medical and public health programme must have a very sound infracture of overall social, cultural and economic development. In a natural process of social evolution, medical and public health services cannot grow without such an infrastructure. Even if it were hypothetically possible to create artificially (at an astronomical cost) efficient medical and public health services without correspondingly developing in the infra structure, the social benefits accruing from such services will be of doubtful significance. What benefits will a hypothetical 'disease free' state bring to a population that is otherwise ill-fed, ill-clad, ill-housed and illiterate?


Radha Narayan, Susy Thomas, N Srikantaramu & K Srikantan: Indian J TB 1982, 29, 98-103.

Illness is mostly a subjective awareness of an individual, the relief of which may be sought within or outside medical or health facilities. Perception of illness vary from people to people depending upon cultural, ethnic and socio-economic differences. Perception of symptoms by persons suffering from tuberculosis is very high yet only half of them approach modern medical facility for alleviation of their suffering. A survey was carried out in rural area of Hoskote taluk, Bangalore district to determine perceived morbidity and accessible medical relief in 1433 households belonging to 18 villages; of them, 1393 (97%) were successfully interviewed. Selected households belonged to three types of villages i.e., those being within 3 kms of a i)PHC, ii)taluk headquarters hospital and non- Governmental health centre.

Of the 9286 individual belonging to 1393 households satisfactorily interviewed regarding health, 1201 (12.9%) were found to be ill at some point of time during the reference period of one month. No differences were observed in the perception of morbidity or in the health seeking behaviour in the three groups of villages. Persons with symptoms/disease accounted for 88.8% of the total sickness, 3.4% for injuries and 9.3% for disabilities, while action taking was 61.6%, 90% and 13.5% respectively. Age sex distribution showed no difference in illness occurrence. Sputum was collected from 147 chest symptomatics and seven were found to be sputum positive. Government health facilities were utilized by 37.6% of the sick persons, private doctors by 36.4%, nature medicine by 10.6% and home remedies by only 9.9%. In conclusion, the services at the government health facilities were acceptable and were utilized if accessible. Prompt and adequate relief for injuries and acute indispositions ensures confidence of the people and better utilization.


A : Problem Definition
SS Nair: NTI Newsletter 1977, 14, 20-24.

The Health Intelligence System has to provide information for the planning, monitoring and evaluation of the Health Services which are provided by the Health Care Delivery System in the country. The Health Intelligence System should also be in a position to provide information on the health needs and demands of the community so that the Health Care Delivery System can plan to meet the unmet demands and needs. Information available is quite often incorrect, incomplete and out dated. Appreciable improvements can be effected only on the basis of a critical appraisal of the system. Some of the important reasons are lack of training, aptitude and sense of involvement in the work by the staff, improper reporting proformae, enforcement of targets, absence of discrimination between routine and special health intelligence, quantitative and qualitative data and lack of systematic & regular supervision by health administrators particularly at the district level. Suggestions for improvement are better utilization of collected data, simplification of proformae, adequate training to the staff in health intelligence, realistic variability of targets, integration of health intelligence for various components of the health care delivery system, bifurcation of data into two i.e., simple routine use and for use for special purposes and regular and systematic supervision and make suggestions for taking top level decisions. The major gaps and other problems listed in this paper and the suggestions made to overcome these are of such nature that these have to be considered at top levels and decisions taken, preferably on the basis of the observations and recommendations of a study group of experts set up for the purpose. Until some basic changes are made, the Health Intelligence System will continue to be thoroughly inadequate for proper planning, monitoring and evaluation of the Health Care Delivery System.


Radha Narayan, Pramila Prabhakar, S Prabhakar, N Srikantaramu: NTI Newsletter 1987, 23, 91-103.

National tuberculosis programme reaches people through PHCs and sub centres. A study was conducted to find out the perception of illness and utilisation of health facilities by the community. This study was conducted in a random sample of 48 villages selected according to Probability Proportioned to Size within 5 Kms of the selected PHIs in Kolar District using a Multi stage sampling technique. Information on socio economic status, availability of health services and their utilisation was collected. 13,323 individuals were interviewed. 706 were ill in a period of two months prior to survey. 71.3% had taken allopathic system of treatment. 69.1% had approached government hospital or PHC. 34 patients reported to have TB. All had attended either DTC or PHC.

The study indicated that morbidity was perceived much early and also followed by an action. Data indicates a high percentage of preferring allopathic system in general and from peripheral health centres and other Government hospitals in particular. Data indicates that in spite of overall backwardness of the study area and very limited economic resources people have utilised the PHC to the maximum. The reason could be either high acceptance of PHC or inevitability. But, there is an evidence of higher utilisation of family welfare and MCH services. The data shows all tuberculosis patients have had exposure to standard regimens, all of them have approached either PHC or DTC for treatment. This confirms the felt need oriented concept of National Tuberculosis Programme. Also high level morbidity among children below 4 years of age and action taken indicate an enhanced level of demand for health services.


Baily GVJ, Kul Bhushan, GE Rupert Samuel & BK Keshav Murthy : Indian J TB 1973, 20, 155-60.

BCG vaccination is being conducted as a mass campaign. It is difficult to maintain a high coverage of the population at risk i.e., new borns. This can best be done by integrating the BCG vaccination services with the general health services. The present investigation was planned to study the feasibility of routine BCG vaccination of the new borns by the Primary Health Centre personnel using the normal records maintained by them. In a rural population of 33,128 persons (1971 census), served by PHC Bettahalasur of Bangalore district, BCG vaccination was administered to 0-15 months old children by 2 Block Health Workers (BHWs) and 3 Auxiliary Nurse Midwives (ANMs) after training them for about 3 weeks. They used a compact specially designed BCG kit and employed a conventional intradermal technique for BCG vaccination. Routine work was not to be disturbed in any way. Each worker prepared a list of children eligible for BCG vaccination from the register of unprotected children and updated the list for those not found registered. National Tuberculosis Institute (NTI) field staff registered a sample population, allotted to each worker for estimation of eligibles. Three months later they also examined BCG vaccination lesions in a sample of children. BHWS and ANMS were interviewed by a medical officer from NTI regarding their opinion on integrated work.
The findings showed that the ANMS and BHWS had already registered nearly 50% of the new borns in their records with variation in registration from 21 to 80% by the field workers; ANMS understandably having registered lesser numbers. All of them were, however, able to update the registrations to a level of 82%. They could pick up the BCG vaccination technique easily. Of the total eligibles, ANMS and BHWS could contact 86.4% and vaccinate 77%; remaining 23% either refused or were excluded from vaccination. In the total eligibles registered, however, the vaccination coverage was 66.6%. Of the children reported vaccinated, 96% had evidence of BCG vaccination indicating a high degree of reliability of reporting. The opinion of all the 5 field workers on integration was favourable. All the ANMS and BHWS workers, on interview, stated that they had done BCG work without detriment to their other duties and would be easily able to do so in future. The field workers can accumulate the new borns for a year and vaccinate them during a month. This has mainly operational advantages including less vaccine wastage. For urban areas a different operational design with the same principles may become necessary.


C : Health Survey
National Tuberculosis Institute, Bangalore-Report on the Baseline Survey-DANIDA Health Care Project, Tamil Nadu, 1988, NTI, Bangalore, Vol. 1, 1-88.

SURVEY DESIGN : A baseline survey was carried out in Salem and South Arcot districts of Tamil Nadu which were covered under the Danish International Development Agency (DANIDA) Health Care Project. This work was entrusted to the National Tuberculosis Institute (NTI), Bangalore, which had more than twenty years experience in conducting large scale surveys in the health sector. Overall guidance was provided by a Steering Committee under the Chairmanship of Director (Evaluation), Ministry of Health and Family Welfare, Government of India. The baseline survey of the demographic-cum-socio economic features, health status and utilization of health services was considered necessary to provide bench mark data on the beneficiaries. Equally important was to have basic information on the rural health care delivery system so that the inputs could be directed towards factors that needed strengthening and the benefits accruing maximized. The rural area of Salem and South Arcot districts were bifurcated into two strata. Stratum I consisted of all villages in which a Primary Health Centre (PHC) or sub-centre was located and the remaining villages constituted Stratum II. A sample of 40 villages were selected. The equal number of villages were allocated in each stratum, proportional to its share of the total rural population of the district. The selection of villages was made with probability proportional to size (population) of the villages, after stratification by size. Every fifth household was selected on a systematic random sample basis from each village. Thus, 2,000 households were selected in each district and 4,000 in the project area. In all, eight questionnaires were prepared for the baseline survey-four for collection of information from PHCs, Medical Officers of PHCs, Field Health Workers (FHW) and Trained Birth Attendants (Dais) and the remaining four viz., Household Schedule, Morbidity Schedule, Eligible Women Schedule and Children Schedule from the selected households. The field work was carried out during July to November 1983 by twenty investigators specially recruited and trained by NTI under the close supervision of five experienced Social Investigators of the Institute. Keeping in mind the importance of high coverage, the field teams put in lot of efforts and thereby succeeded in collecting information from 99.7% of the 4,000 households selected for the survey. Method of data collection for MOs was through a pretest questionnaire, for PHC through a questionnaire-cum-interview schedule, for FHW and Dai through interview schedule and village appraisal was done through group discussion (group consisted of village officials, informal leaders, members representing different castes, classes and women). The collected data after careful scrutiny by the statistical staff of the Institute was analysed, tabulated and reported.

FINDINGS: I. Socio-economic features: a) Literacy : Nearly half of the population of age five or more were illiterate. SC/ST population had more illiterates (58.9%) than "others" (45.8%) and had less who had school education of any level. Percentage of literates without schooling was negligible. There were no literate females in 53.8% of households (60.5% among SC/ST). In 24.9% of the households the highest level of female education was I to V standard and 17.7% VI to X standard. b) Employment: In the labour force of age group of 15-49 years, about 60% were employed. Employment among older persons was 53.5%. Children of 10-14 years of age, 6.3% were employed. This was about five times higher in Salem compared to South Arcot. Out of these employed, 45.2% were general labourers, 23% agricultural labourers and 20.6% artisans. Child agricultural labourers were more among females. The large percentage of persons who are not fully occupied for the whole year (about three-fourths of those aged 15-49 years and a substantial proportion of the elderly persons and grown up children) could be mobilised during their slack periods to carry the message of better health and hygiene as well as of the small family norm and thereby improving their financial condition also to some extent. c) Assets: About half of households did not possess any land and about 30% had less than two acres. Those not possessing any land were more among SC/ST (67.6%). Productive assets were not possessed by 65% of the households. d) Living conditions: Cowdung smeared floors were most common (65%) followed by cement floor (25%). This was more common in South Arcot (76%) compared to Salem (51%). Kerosene was used for lighting by 69% and electricity by 29%. Most of the households used foraged firewood (68%) for cooking. Almost all households (96.0%) let out used water into open place. Household waste was thrown into open yard by 65.0% and 34.6% used manure pit. Open field was used for human waste disposal by 98.4%. Provision of better sanitation arrangements and education for their utilisation needs to be taken up on large scale. The most common pests were mosquitoes (88%), flies and ants (76%), rats (40%) and cockroaches (27%). Nearly all (89%) did nothing to control these pests. The reason for this have to be investigated and suitable steps taken to remedy the situation. e) Staple diet: Main type of food was rice (50%), ragi (30%) and millets (20%). f) Major problems: The major common problems were non- availability of water (54%), health facility (49%) and transport (26%). All the three were mentioned by more households in Salem. More SC/ST households mentioned non- availability of "water" and "transport".

II. Demographic profile: The estimated rural population of 64 lakhs in the project area at the time of the survey (second half of 1983) compared favourably with that of 60 lakhs from the 1981 census. Of the population of age 15 years or more, 67.9% were currently married and 21.5% never married. The birth rate for 1982 is estimated to be 30.0 per thousand population as compared to SRS estimate of 27.7 for Tamil Nadu. The birth rate was higher in South Arcot and in Stratum II. The birth rate among SC/ST was higher in both strata of both the districts. About 98% of total births were live births. Fertility was highest in the age group 20-24 years (254) followed by 25-29 years (206) and 30-34 years (143). It was higher in South Arcot for 25-29 years, 30-34 years and 40-44 years as compared to Salem. The death rate for 1982 is estimated to be 11.0 per 1000 population. The infant mortality rate for 1982 is estimated to be 34 per 1000 live births compared with census. This gross under estimate may probably be due to some reservation or reluctance to report infant deaths possibly due to practice of infanticide by some sections of the population. As stated earlier, the proportion of child deaths out of total deaths was nearly double among females as compared to males. Of the eligible women (currently married and of age 15-49 years), 22.1% were in age group 25-29 years, 20.6% in 20-24 years, 18.0% in 30-34 years and 16.3% in 35-39 years. Thus, 42.7% were in the age group of 20-29 years with the highest fertility. Almost all eligible women had only one marriage. They had married more frequently at the age of 15-17 years (46.0%) followed by 18-20 years (32.7%). While 11.7% of the eligible women had no child. 38.8% had the first child at 18-20 years and 28.0% at 15-17 years. At the time of the survey about one tenth of the eligible women were pregnant.

III. Morbidity: During the month prior to the survey 15.4% were sick (22.2% in South Arcot and 10.6% in Salem). Among the common diseases during the three months prior to the survey, fever/flu was mentioned by 27.9%. Common cold/cough together with conditions affecting the respiratory system were reported by 22.6% and occupied second position. Conditions affecting the digestive and excretory systems (including stomach ache) were mentioned by only 13.4%. This is quite surprising since only 23.3% of the households used tap water for drinking. The 70% of households who used ground water for drinking were apparently getting water without contamination. About 42% of the sick persons did not seek treatment. This proportion was more in South Arcot (47%) compared to Salem (33%). The reasons for such a large proportion of the sick persons not seeking treatment needs to be investigated. While 39% of those who sought treatment did so from Government Health Institutions, 34% went to private doctors/institutions. More than half did not spend any money on treatment. About one fifth spent less than Rs.50/ and 7.3% between Rs.50/ and Rs.100/ . Tuberculosis prevalence rate was 5.3 per 1000 population and is well within the expected range obtained from sophisticated and costly prevalence surveys. Among the tuberculosis cases, nearly 90% had cough for 15 days or more. More than 95% of the cases had taken action to relieve their symptoms and the vast majority had gone to Government Health Institutions. Some tuberculosis cases had visited more than one type of health institutions in search of treatment. These findings are also quite similar to those obtained from sociological investigations in the field of tuberculosis. Prevalence rate of leprosy was 1.8 per 1000. The disease was more common in South Arcot (2.7) compared to Salem. When anyone is sick, 61.5% of the households go to Government doctor, 81.3% among SC/ST against 55.0% among "others". Services of private doctors were availed by 35.7% (16.9% among SC/ST compared to 41.9% among "others"). About 60% travel 5 kms or more to get treatment from Government or private doctor. The main reason for going to Government doctor was free treatment (75.4%). Only 15.0% felt that the treatment by Government doctor was good compared to 81.2% who considered that treatment by private doctor was good. Among various facilities available within 3 kms, 29.7% of households utilised the services of doctor of modern medicine, 26.1% of homeopath and 13.2% vaidya. Among those who had availed services at Government hospitals or PHC, 63.0% and 68.7% respectively had no difficulty. The more frequent difficulty mentioned was "long waiting time". During the two months prior to the survey, 53.5% of the households were visited by female health workers. More households were visited in South Arcot and among SC/ST. Family Planning: About one third of the births were attended by relative or friend, 19.4% by untrained Dai, 17.4% by doctor. Among currently pregnant women, only 32.2% had registered for ante natal care. About 60% were not given any dose of tetanus toxoid, while 15.4% got one dose and 10.7% two doses. Less than half of currently pregnant women had received iron and folic acid. About two thirds of the deliveries were conducted at home (73.9% in South Arcot compared to 56.5% in Salem and 77.3% among SC/ST against 62.2% among "others"). About one fourth of the mothers were assisted by doctors at the time of delivery, 27.0% by Dais, 9% by Female Health Workers and 35.7% by others. Help by Dais was more common in South Arcot. Currently married women of age 15-49 years (eligible women) were 161 per 1000 population. Nearly three fourths of them were illiterate (82.4% among SC/ST compared to 69.3% among "others"). About one fifth of the eligible women had tried to prevent pregnancy, the vast majority by using family planning methods. Though efforts to prevent pregnancy were comparatively more among literates, the difference was quite small. Those with 3 or 4 children more often tried to prevent pregnancy. This is not likely to have much impact on curbing of population growth. About 65% of those sterilised were below 30 years of age and the mean age of sterilisation was 27.9 years (27.3 years in Salem compared to 28.7 years in South Arcot). About half of the sterilisations were done soon after delivery, percentage of sterilised steadily decreased with increasing age of youngest child. More than three fourths felt that there was no advantage or disadvantage in having a large family. While 10.5% felt that large family led to more income, 8.5% felt that it was a burden. Among the family planning methods, male and female sterilisation were known to 94.0% and 95.8% respectively. Nearly half of the eligible women stated that they have not seen the red triangle in PHC/SHC. Those who have seen and understood the message formed only a small proportion. About two thirds of the eligible women did not know that abortion can be done at Government hospitals and 71% did not know that it can be had free of cost.


National Tuberculosis Institute, Bangalore: Report on the Baseline Survey Danida Health Care Project Tamil Nadu, 1988, NTI, Bangalore, Vol.2, 1-23.

A comprehensive baseline survey was undertaken in two contiguous districts of Salem and South Arcot of Tamil Nadu for strengthening the health and family welfare services with the assistance of the Danish International Development Agency (DANIDA). The main objectives of the study were to obtain data on the prevailing health status of population, the village organisations and leadership in health matters and important aspects of the health system of the area, such as Primary Health Centre (PHC), Medical Officer (MO) and para medical personnel identified as field health workers.

a) Medical Officers: A questionnaire was canvassed by post mainly in June/July 1982 after briefing the Medical Officers at their monthly meetings at Health Unit Districts. Out of 221 posts of Medical Officers (MOs) in 72 Primary Health Centres (PHCs), 68 were vacant. Of the 153 MOs in position, replies were received from 119 (78%), 69 in Salem and 50 in South Arcot. Among these MOs, 87 were men and 31 women, and 71% were in the age group 30-39 years. Proportions of married were 87% in men and 71% in women. Of the 119 MOs, 111 were qualified in allopathic system of medicine. Though 52% stated that they had training in rural health services, only 26% mentioned that they were trained at Health & Family Welfare Training Centres (HFTC). About 50% of MOs had total work experience in Health Department of 1-4 years and 25% of 5-8 years. Of the average service of 4.62 years in this department, 3.09 years were in the PHCs where they were working at the time of the survey. The overall ranking of functions of MOs was 1) curative (60.5%), 2) Preventive (41.2%), 3) Promotive (23.5%), 4) Supervision (35.3%) and (5) & (6) Public relations (23.5% and 41.2% respectively). Administration had the highest percentage for 2nd and 4th rank. MOs trained in rural health, however, had given more importance to working with block officials as compared to other MOs. Though nearly 75% MOs had stated that they plan a weekly schedule of work, while giving the detailed schedule, a maximum of 48 MOs had included outpatient clinic on any day of the week and the position with regard to important managerial functions and rural services was much worse. About one third did not conduct any mobile clinic during the month prior to the survey; 28% did not answer the question and the remaining 40% had conducted 2 or more clinics. Most of them have provided curative treatment and not promotive or preventive services. About 43% stated that there were no voluntary organisations working in their area and more than 80% of MOs stated that private medical practitioners did not take any help from them. About 50% said that neither the private practitioners nor voluntary organisations participated in the health activities i.e., immunisation, health camps and family planning, conducted in the villages. About 22% stated that villagers did not participate in the health activities. While 23% had no difficulty in working at PHCs, 30% mentioned lack of facilities at PHC, 18% each stated personal problems, heavy work load/lack of staff and more administrative work and 16% transport problem. About 30% mentioned that there were no problems, 44% mentioned staff vacancies, 24% lack of cooperation from staff and 14% staff changes. While 47% found no advantage in working in a PHC, 27% mentioned about provision of better services to the rural areas, 18% about better understanding of basic health problems and 8% wider experience including management. About one third only gave the relevant suggestions for improvement of the centres. The MOs at PHCs can play a crucial role in the delivery of health services in rural areas. They are the leaders of the health team at the grass root level with adequate technical knowledge and a very high degree of acceptability. The findings of the present study are therefore, very valuable and the shortfalls and deficiencies listed below have to be given adequate attention: i) All posts of MOs and staff to be filled. ii) Provision of facilities to staff at PHC. iii) MOs should give more attention to public health activities. iv) Adequate supervision of work of MOs and special training to them in rural health.

b) Primary Health Centre: In the rural areas, Primary Health Centre (PHC) is the nerve centre of the health services both institutional and community oriented. It was planned to obtain some basic data on the organisational structure, area of responsibility and functioning of PHCs and utilisation by the people of the services provided by PHCs. All the 72 PHCs in the project area were studied through a questionnaire cum interview schedule. Further, data and clarifications were obtained through interviews from the Medical Officer In charge of PHC and knowledgeable staff such as Health Inspector (General) and Block Extension Educator. The data were collected during June 1983 to January 1984. The area of coverage of 82% of PHCs was within 300 sq. kms., 194 sq.kms in Salem (District I) and 237 sq.kms in South Arcot (District II). Thus, PHCs in South Arcot generally covered more area and more villages and served larger populations. About half of the PHCs could not provide information on scheduled caste and scheduled tribe populations who are part of the target population under the project. Out of 1175 sub centres for which information was available, 72% were within 20 kms. of PHC. This was so for 84% of 548 sub centres in District I but only for 62% of 637 sub centres in District II. The average distance of sub centres from PHC was 12.3 kms. in District I, 18.4 kms (one and a half times) in District II and 15.7 kms at project level. Organisation: The average number of villages per sub centre was almost the same in both districts (3.3 and 3.4). A sub centre covered an average population of 4,800. All but two PHCs were in standard building and all were electrified. Nearly half of the PHCs were located outside the village after which it was named. No other medical facility was available within one kilometer reach in 40% of PHCs in District I and 70% in PHCs in District II. Vacant posts were more among Medical Officers (37.6%) and Medical Officers (indigenous) (36.4) and less among para medicals (16% among supervisors and 10% among workers). While about one third of the PHCs did not have separate laboratory, about half did not have separate injection/dressing room and Minor OT. While most of the PHCs had refrigerator and microscope, 77% of the former and 93% of the latter were in working order. Functions: The main training activities of PHCs were Dais Training & Orientation Training Camps for which the average number of courses per PHC during the year prior to the survey were 3.1 and 2.6 respectively. Health education activities were mainly confined to group meetings and distribution of publicity material, with average annual performance of 70.3 and 53.8 respectively. Average outpatient attendance per PHC during the previous year was about 36,500 of which 19,600 were new outpatients. On an average, 98 patients were admitted in beds in a PHC (120 in District I and 71 in District II). For all the MCH activities except distribution of iron and folic acid to women and giving polio vaccine to children, District II had fared much better than District I. While for the other two activities mentioned above District I fared better. There was no uniformity between PHCs and districts in the number of tablets of iron and folic acid given per woman. Tuberculosis : The average percentage of persons with symptoms of TB was 1.8 (2.1 in District I and 1.5 in District II) as compared to the expected rate of 2.6% based on a study by the NTI. Identification of symptomatics from new out patients is on the low side, particularly in District II. As against the expected positivity rate of 10% among sputum smears examined, the rate was 14.4% (8.1% in District I and 21.4% in District II). The reason for such differences need to be studied in depth. Leprosy : Since leprosy work is carried out by special teams, most of the PHCs are not aware of the work done in their areas. Malaria : The average rate of fever cases identified per 1000 population during the month prior to the survey were 8.1% and 15.7% respectively. The figures for blood smears made were almost the same. The average number of persons given anti malarial drugs (mostly chloroquine) per 1000 population were 8.0 in District I and 20.7 in District II. Chlorination : In District I where a PHC covered an average of 51 villages, 84 wells were chlorinated during the month prior to the survey. The corresponding figures for District II were 111 villages and 89 wells chlorinated per PHC. Registration of births & deaths : The birth rate on the basis of births recorded by PHCs was 13.3 per 1000 which is less than half of the birth rate for Tamil Nadu for 1983. The recorded death rate was 8.3 per 1000 as compared to an expected death rate of 11.5. Recording of births and deaths needs considerable improvement in almost all PHCs. Referral : Among 64 PHCs who gave information on referral of patients for tertiary care, 21 referred to one hospital, 34 to either of two hospitals and 9 to anyone of three hospitals. Records & Reports : Surprisingly, PHCs gave a wide range of answers about the records and reports they maintain. Though there is a general complaint that records and reports are too many, there were hardly any useful suggestions about which records and reports could be simplified and reduced. Targets : Another surprising finding is that there was no unanimity in the answers from PHCs about the units of period for achieving targets under national programmes. Supervision : With regard to supervision of non- medical staff at PHC there was no uniform pattern. Medical Officers carry out field visits mainly for either control of epidemics or to pay surprise checks. Collaboration : Most of the PHCs did not seek collaboration of other Government departments, voluntary organisations or community leaders. The limited collaboration sought was mainly for Family Welfare Programme. Only about 60% of PHCs felt that the community can participate in Immunization, 52% in Family Welfare and 15% in Epidemic Control. Most frequent illness : Conditions affecting digestive and excretory systems were mentioned as the most frequent illness in their area by 38 out of 68 PHCs, followed by conditions affecting respiratory system by 32 PHCs, pyrexia of unknown origin by 20 PHCs, and skin diseases by 14 PHCs. Health problems : When asked about the health problems in villages, replies from PHCs dealt with diseases (illness) problems only.

The main weakness of the PHCs was observed with regard to management, inter departmental collaboration and community involvement as reiterated below: At least 40% of PHCs did not have 1981 census figures for population. Further, about half of them did not have population figures for scheduled castes and scheduled tribes. Recording of births and deaths are far from complete. Further, there is considerable indifference towards maintenance of all records and reports. The Medical Officers In charge, do not supervise the other Medical Officers of PHCs. Their knowledge about functions of para medical staff was inadequate. Under these circumstances neither could the Medical Officer In charge ensure adequate and proper supervision by the para medical supervisors nor guide them in their work. Acute shortages of Vitamin "A" and general medicines were reported. So also for mass media equipments such as film projector and sound system. Collaboration with other departments and voluntary organisations was quite weak. Contacts with community leaders either to understand the health problems as conceived by them or to seek the co-operation of the community were also at a low ebb. IUD insertions which benefit the younger couples or those with small families were quite negligible and the stress was on sterilisation only which benefit mainly older couples or those with already large families. Health education activity of PHCs was at a very low ebb.

c) Field Health Worker : The field health workers who consists of Health Workers (HWs) and Health Supervisors (HSs) were identified as important para medical workers. They play the most crucial role as they have daily contact with the rural population in their homes. The main objectives were to obtain a profile of field workers, to ascertain the area of responsibility, health services rendered by them, community responsibilities and supervisory functions of the HSs. The information was collected through pretested interview schedule. Of the 326 HSs and 2349 HWs in position, 165 were interviewed. The majority of male HWs were of age 30-39 years, while female HWs were of age 20-29 years. All the HSs and all but one of the male HWs were married. Among female HWs, half were married and about 88% of female HSs were married. Vast majority of HWs and HSs had education upto secondary level. The pattern with respect to these profiles was similar in both the districts. Of the male HWs 65% and of the female 32% had training in multi purpose work. While 83% of male HSs and 45.5% of female HSs had multi purpose work training, supervisory training was received by only 1.8% of male HSs and 9.1% of female HSs. With regard to total experience in the health and family welfare department, male HWs had more experience than female HWs. The difference was even bigger in average years and experience between male and female HSs. On an average, 6 villages were allotted to male HW and 4 to female HS, a male HW had to cover an average of 2291 families as compared to 1014 for a female HW. On an average, HW had to travel 6.8 kms to cover the villages allotted. The male HWs approached the villages by cycle or walk while female HWs by walk and bus. Availability of trained dais in the villages was reported by 40.9% of HW(F)s as compared to 50% of HW(M)s. Similarly, according to them about half of the villages have community leaders. Contact of HWs with such bodies need improvement. To the question on number of patients attending SHC services, 80% did not give an answer. The average attendance by HW(F)s was 7. Services given by HWs in villages allotted were malaria, FP & HE. The services received lower priority were TB, environmental sanitation, school health and registration of births and deaths. While 76.3% of HW(F)s maintained that they have a weekly schedule, only 46% of HW(M)s have weekly schedule. On an average during a month HW(F)s worked for 22.4 hrs and HW(M)s for 23.0 hrs in the village. On an average, 12 households are covered per hour. About three fourths of HW(M)s stated that they carried paracetamol to the village, 19.2% sulpha guanidine and 15.4% chloroqine. Among HW(F)s, 76.3% carried anti anemic drugs, 68.4% multi vitamin tabs and 47.3% anti malaria drugs. No medicine was carried by 44.3% of HS(M)s, and 24.2% by HS(F)s. Only 54% of HW(M)s and 74% of HW(F)s mentioned that they provided family planning services in the villages. Supervision of FP work by HSs is also very poor. Few HWs and HSs carried nirodh, oral pills or FP register when they visited the villages. Complaints that the high target for FP hampered health activities appears to be a cover up only. About 45% to 69% of health workers and supervisors said that TB work was not applicable to them. Similarly 42% to 50% also mentioned that nothing to be done for diagnosis of leprosy. Regarding the aspect of their work which are supervised by their supervisors, many did not reply and the others gave a variety of isolated answers. There is urgent need to give training to medical officers and health supervisors on how to carry regular qualitative supervision. The HWs make frequent visits to PHCs, some of them going once a week. This may interfere with the actual work in sub centres.

d) Trained Birth Attendant : In spite of the request to the PHC staff and village leaders to ensure that the trained dais of the selected villages were present, only 24 out of the 80 Dais were present during the survey. They were interviewed. About 54% of them belonged to families in which women attended to births by tradition. About 63% were illiterate, 29% had a monthly income of Rs.100/ or more. Fifteen belonged to backward classes seven to SC one each to ST & Christianity. Two thirds were trained before project started. Over 90% had experience of 5 years or more. Only two thirds of the trained dais have received the kits and less than half had received practical training in conducting deliveries. Different aspects of ante natal care were mentioned as follows: 82% periodical check up, 59% tetanus toxoid and 46% iron and folic acid. The number of deliveries conducted by trained dais was the same as before and after training. Majority of dais do not report births to health personnel. About 75% of the trained dais had referred at least one woman for delivery to ANM or hospital during the previous month. Eleven of the 24 dais, had no difficulties in carrying out their work while an equal number mentioned inadequate regular income. Trained dais were mostly aware of ANMS but not of Basic Health Worker, Malaria Worker or Health Inspector. Neither educational status nor experience had any influence on the functioning and working pattern of the trained dais. There were equal number of untrained dais, it would be worthwhile to train them also. Dai is important liaison between PHC and village for child births, post-natal care, family planning and registration of birth. Some future thought had to be given about their regular income, providing of kits, the replenishment and supervision during frequent visits by Health Workers and Health Supervisors. This will go a long way in ensuring co-operation from trained dais and in boosting up the morale of these village level workers of low socio economic standing which will make them useful participants in grass root level health activity.

e) Village Appraisal : Appraisal of the villages with their multi sectoral needs and activities would provide a third dimension to the survey. An appraisal of sample villages was conducted along with the household survey during June-November 1983. The method of group discussion was adopted to collect the data for village appraisal. Group discussions were held separately for SC & ST so that they could express their views freely (Adi Dravida colonies). This report is based on the information collected through group discussions in 71 main villages and 35 Adi Dravida(AD) colonies. About 45% AD colonies did not generally avail of services at PHC and one fifth did not avail of any service from HWs. Most of the groups felt that allopathic doctors were accessible to them followed by homeopaths. Contrary to expectations accessibility to practitioners of Indian system was poor. ANMs were more accessible to main villages than AD colonies. More than three fourth of main villages and AD colonies stated accessibility of dais. Most of the general facilities were accessible to a large extent except community centre and library. One of the main source of water was pucca well for three fourths of people. About 40% mentioned kutcha open well or river/canel. Latrines were few. Open field was generally used. Both manure pits and scattering was used for disposal of refuse to a large extent. Nearly all let out sullage to open places. About 50% of the villages mentioned that there was no developmental activity during last 12 month period prior to this appraisal. The activities mentioned more frequently were mid day meal scheme, water supply, school building, road construction and health centre. Most of the villages were not aware of who had taken the initiative for these activities. About 10% stated that there were no TB & leprosy cases among them while most of them mentioned DTC, general hospital or PHC as source of treatment of TB. Major problem of the villages were lack of water, transport and communication. Others mentioned were facilities for treatment and for education. Participation of women and younger generation in the group discussion was more in AD colonies than in main villages. According to villagers fever was the most common illness, followed by gastro intestinal disorders, diseases of respiratory system and eye complaints. Main causes of ill health were lack of sanitation and protected water supply. The perceptions by villagers pointed out the need for not only improving the availability and accessibility of service facilities but also for educating the villagers about how these could be made use of. The bigger and most important gaps would appear to be the provision and/or utilisation of preventive and promotive services, in availing of treatment facilities at PHCs and in reporting of births and deaths. Community involvement in all development activities would lead to informed participation in all developmental activities.