A rural population of 65,000 belonging to 119 randomly selected villages of Bangalore district was repeatedly examined four times during 1961 to 1968, by tuberculin test, X-ray and sputum examinations, to study the epidemiology of tuberculosis without any active anti-tuberculosis measures. The interval between the first and the fourth examination was 5 years. The coverage of various examinations at different surveys were very high.

The main findings of the study are: Prevalence rate of tuberculous infection in the population was about 30% (among females 25% and males 35%). The overall prevalence rates of infection were fairly constant at all the four surveys, but a steady decrease in the prevalence of infection was observed in the age group 0-24 years. Annual incidence rate of infection on the average was about 1%. During the study period, the incidence of infection showed a decline from 1.63% to 0.8% for all ages combined. Prevalence rate of disease ranged from 337 to 406 per 1,00,000 population during the study period, the highest being at the time of first survey and lowest at the time of third survey. For the younger age group of 5-34 years, the rates showed continuous decrease during the study period. Annual incidence rate of disease ranged from 79 to 132 per 1,00,000 population, highest being between first and second surveys and lowest between second and third surveys. The incidence rate in younger age groups below 35 years showed a decline during the study period. Those with tuberculin test induration of 20mm or more had highest annual incidence rate of disease. The annual incidence rate of bacteriologically confirmed disease in the three radiological groups of population was (i) 185 per 1,00,000 with normal X-rays, (ii) 958 per 1,00,000 with abnormal shadows judged as inactive tuberculous are non-tuberculous and (iii) 4,530 per 1,00,000 with abnormal shadows judged as active or probably active tuberculous but bacteriologically not confirmed. The third group constituted 1% of the total population and contributed 34% of the total incidence cases. In each of the above three radiological groups, the incidence of disease was highest among those with tuberculin test induration of 20mm or more to 1 TU RT 23 with Tween 80. Those with 20mm or more tuberculin test induration in the third radiological group constituted 0.45% of the total population but contributed 27% of the total incidence cases. Incidence rate for males was nearly double that of females. More than half of the new male cases were 35 years of age, whereas more than half the females were below the age of 35 years. Out of 126 cases followed up at three subsequent surveys over a period of 5 years, 49.2% died, 32.5% got cured and 18.3% continued to remain sputum positive. Both death and cure rates were highest during the first one and a half year period.

About 30% of newly detected cases come from population uninfected at an earlier survey. Both infection and disease showed a decline in the younger age group. There was no evidence of an increase in drug resistance among newly diagnosed cases. Incidence of cases showed a higher natural cure. These findings indicate that tuberculosis cases are not a uniform entity. There can be different gradations from the point of view of diagnosis and ability to benefit from treatment. The differences between male and female patients with regard to death and cure rates support this view

A methodology in brief about conducting Classical Tuberculosis Sample Survey and Tuberculosis Surveillance is given below:

I. CLASSICAL TUBERCULOSIS SAMPLE SURVEY
A tuberculosis prevalence survey to measure the problem of tuberculosis in the community is a challenging assignment especially so when it is to be conducted by an organisation not created with the specific objectives of carrying out research work e.g., the District Tuberculosis Centre, State Tuberculosis Centre, etc. However, following procedure is described in brief: (1) Selection of district for the study, (2) Collection of basic data like size and distribution of population, number of towns and villages, (3) Selection of sample population for survey by valid statistical methods, (4) Census enumeration of study population by trained census takers - preparation of cards for all the individuals, (5) Tuberculin testing & reading of all subjects under study, (6) BCG scar survey, (7) X- ray examination of the eligible population (> 10 years or > 15 years). Interpretation of X-rays by standard readers, (8) Collection of sputum from chest symptomatics and X-ray abnormal individuals, (9) Transportation of sputum to central laboratory (necessary precaution to be taken during storing and transportation), (10) Sputum to be examined by trained staff, (11) Compilation, analysis and interpretation of data. Number of working teams with full complement of staff depends upon the size of the study population and the time frame of the study. An average survey team may have the following personnel on its strength: Medical Officer - One, Census Takers - Three, Tuberculin Tester & Reader (one each) - Two, Lab Technician - One, Lab Asst. - One, X-ray Technician. - One, Dark room attender - One. Equipment required: Mobile X-ray unit - mounted on a jeep along with the generator mounted on another jeep, Laboratory infrastructure, Vehicles preferably jeep.

Apart from the above, the team may need part time assistance of a Statistician and a few Statistical Computers. In case a state is interested to carry out an epidemiological survey, it may need to create the above infrastructure. Once arranged, it may request the National TB Institute (NTI) to train the required staff on standard survey techniques under field situations which is very essential.

II. TUBERCULOSIS SURVEILLANCE
In contrast to the more complex methodology involved in a classical survey described above, an alternative, much simpler and indirect method to assess the problem of tuberculosis in the community is by finding out the infection rate, through tuberculin surveys. It may be possible to estimate the prevalence of sputum smear positive disease from infection rate. Such survey is conducted by subjecting the age-specific unvaccinated population to tuberculin test periodically. For carrying out the work, one to two teams composed of three to four properly trained tuberculin testers and readers are needed along with at least two vehicles and a standby vehicle per team. Budgetary support for petrol, travelling and daily allowance of staff, and for minor miscellaneous expenditure like stationery, spirit, etc., may be required to be provided. Training could be imparted to such personnel at NTI and their services utilised exclusively for carrying out tuberculin surveys as a regular ongoing surveillance activity. If this methodology is found suitable, one may take action to create posts of tuberculin testers and readers in suitable scales and draft them for training in tuberculin survey methodology. The Institute will be happy to train the required personnel for the purpose, as well as analyse the data so collected for use by the states.

To obtain precise information for computing the indices of tuberculosis situation in a community, with passage of time, reliance has been placed on tuberculosis infection rates obtained by carrying out tuberculin surveys. In most developing countries, covered extensively by BCG vaccination without prior tuberculin testing, the tuberculin test has problems of interpretation for demarcating the infected persons from the uninfected. To overcome the problem, therefore, the test results are analysed among persons who do not show a BCG scar and are, thus, considered as normal population. In this paper, an attempt is made to show that BCG vaccination not always lead to the formation of a scar, and also that the scar resulting from BCG vaccination may fade away with time and the person, thus, may be wrongly included in the unvaccinated group. It has also been found that there is greater fading of scars in the younger age groups: in children 0-2 years of age, upto 52% of the scars faded away within 21 months of vaccination. This proportion steadily decreased to about 8% in the 10-14 years age group.
The implication of the finding is that the demarcation line between uninfected and infected persons may require to be shifted from survey to survey, based on the distributions among the 'no scar' population. Moreover, in a totally vaccinated community, the differences of reactions may provide the answer to the problem of identifying the newly infected persons.

A controlled clinical trial of the three Short Course Chemotherapy (SCC) regimens was carried out at the Lady Willingdon State Tuberculosis Centre, Bangalore and Tuberculosis Research Centre, Madras with the collaboration of National Tuberculosis Institute, Bangalore. The regimens were (1) R3: (rifampicin, streptomycin, isoniazid and pyrazinamide daily for 3 months (3RSHZ); (2) R5: same as regimen R3, followed by streptomycin, isoniazid, pyrazinamide twice weekly for 2 months (3RSHZ/2S2H2Z2); (3) Z5: same as regimen R5 but without rifampicin (3SHZ/2S2H2Z2). Newly diagnosed tuberculosis patients who were aged 12 years or more had no history of previous treatment and two sputum cultures positive for M.tuberculosis were taken to the study and allocated at random to one of the above stated three regimens. The patients were given supervised chemotherapy as out patients. Sputum specimens were examined by fluorescent microscopy, culture by modified Petroff's method, tested for sensitivity to INH, rifampicin, streptomycin and ethambutol. The follow up was done by sputum smear and culture examination at the end of every month for 2 years. The distribution of various pre treatment characteristics like age, sex, and initial sensitivity status were similar in the three series. At the end of 3 months, of the 455 patients on R3, and R5 series, 96% with drug sensitive organism became culture negative and of 235 on Z5 series 93% became culture negative. For R5 and Z5 series favourable response at the end of chemotherapy were 96%, 99% and 97% respectively. In all, 6 patients (3 R3 & 3 Z5) were classified as having unfavourable response. At the end of 24th month from the date of start of treatment, 20% of the 200 patients on R3, 4% of 187 patients on R5 and 13% of 199 patients on Z5 had bacteriological relapse. The difference between R3 and Z5 series was highly significant. (p = 0.00001). The relapse rates in R3 & Z5 series were significantly higher than that in R5. Of the 57 patients with initial drug resistance organisms in R3 and R5 series combined 4 had an unfavourable response to treatment compared with 13 of 26 in the Z5 series (p = 0.0001). Of the 4 patients with an unfavourable response in R3 and R5 series combined, resistance to rifampicin emerged in 2 patients. Complaints of arthralgia were made by 45% of the R3 and R5 patients combined and 70% of Z5 patients (p = 0.00001). However, chemotherapy was modified in only 5 and 12% respectively. Jaundice occurred in 7% of the R3 and R5 patients and 1% of the Z5 patients (p = 0.0001).

The main aim of establishment of State TB Centre (STC) was to provide training to District TB Programme (DTP) key personnel to do research, technical supervision, monitoring, assessment and coordination and assistance to DTPs by constant guidance and feed back. In almost all large and medium size states, there is State Tuberculosis Demonstration & Training Centre (STDTC). These centres were envisaged at the very inception of the National Tuberculosis Programme (NTP) as the superstructure at the state level. The organisation of the centre is according to the functions of STC. It consists of DTP Demonstration Unit, Training, Bacteriology, Treatment Organisation, X-ray, Monitoring and Administrative Sections. The functions are: (i) to organise and conduct training courses mainly for DTP key personnel, short period courses for Peripheral Health Institution (PHI) workers and orientation programme for district and state level health administrators etc. (ii) to carry out the activities as per the DTO Manual in the urban and rural units of DTPs. The urban programme can be formulated according to the local variables, specially in mega cities. However, the guiding principle should be to enlist the participation of as many health institutions as possible. (iii) to provide laboratory services of Level-IV according to the nationwide network classification i.e., the centres carry out culture, sensitivity of mycobacterium tuberculosis besides smear examination for service, research purposes and also imparting training to personnel working in Level-III laboratories. (iv) to train the Treatment Organisers (TOs) of District Tuberculosis Centre (DTC) the responsibility of Treatment Section. (v) to train X-ray Technician (XT) of DTC, guide and assist in proper functioning and maintenance of MMR units in the DTC is the responsibility of X-ray Section which is manned by experienced Sr XT. (vi) to collect information on Case-finding, treatment, staff position and equipment from DTP and carry out supervision and assessment of DTPs is the responsibility of Monitoring Section.

Training of DTP key personnel so far has been carried out solely by National Tuberculosis Institute, Bangalore. Now, the states should also take up the responsibility of training the DTP key personnel. The staff, building, equipments, vehicles and supplies provided in the existing STDTC would be adequate. If required, the additional staff, modification/extension of the building and replacement of equipment/vehicles should be made.

The unit of NTP is known as District Tuberculosis Programme (DTP). The name is derived from the area, as each unit covers a district which is geographically, administratively, politically independent. The performance of the DTP from its inception till 1977-78 was monitored continuously by two centres, Northern Regional Centre (NRC) and Southern Regional Centre (SRC) situated in north and south India respectively. Later on in 1978 when these centres were abolished, National Tuberculosis Institute (NTI) was given the responsibility of monitoring the programme in the entire country. NTI monitors the performance of the programme through the quarterly and annual reports received from DTPs. The results of cohort analysis based on treatment cards of patients under DTP, are reported by the DTC through annual reports, which needs expertise. As a result, not only limited number of reports are received but also some of them are not up to the mark. Hence, it was felt to have a base line study of cohort analysis of treatment pattern of various categories of TB patients treated under DTPs. With the assistance from WHO, a pilot study was carried out in two districts of Mysore & Hassan of Karnataka State for the cohort period of Jan Dec 1991. On the basis of District Case Index Registers, 4053 treatment cards were collected from both the DTPs, of which 3877 were considered for analysis.

Results of analysis are being given separately for each district. In Hassan out of 1564 patients, 259 (16.5%) were smear positive, 1256 (80.3%) suspect cases and 49 (3.1%) extra pulmonary cases. The treatment completion rates for different categories of patients were: smear positive treated with SR 26.2%, with SCC 47.5%, suspect cases 23.3% and extra pulmonary 51%. In Mysore district, there were 2313 patients. Of them, 203 (8.8%) were smear positive, 1706 (73.8%) suspect cases and 275 (11.9%) extra pulmonary. Treatment completion rates for smear positive treated with SR 17%, with SCC 43.8%, X-ray suspect cases 18.8% and extra pulmonary 24.7%. Information on outcome of treatment i.e., cure rates, deaths etc., could not be collected due to incomplete recordings on the treatment cards. It could be concluded that a very small percentage of smear positive cases were detected. Treatment completion rates were very poor for all the categories of patients. There was no difference in the treatment completion rates obtained from the study and reported by these centres to NTI through annual report.

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.

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.