At present most of the districts in India have a TB clinic at the district headquarters, where TB patients are diagnosed and treated. Most of the clinics serve the town population and only a small proportion of the rural population are able to attend the clinics due to long distances. The wide distribution of patients in rural areas will necessitate the provision of extensive anti-tuberculosis services and they should be provided as near to the patients' home as possible. This cannot be achieved by creating large number of specialised services (TB clinics) in the district, as this will not only be beyond the resources but wasteful. As such, provision of anti-tuberculosis services in rural areas can be achieved by integration of the primary health centres and dispensaries. The problems of treatment in rural areas are envisaged as technical, organizational and personnel. Under the technical problems, the choice of anti-microbials is considered. The anti-microbials should be effective, cheap and acceptable to the patients. INH PAS, INH alone or INH Thiacetazone are considered suitable. Streptomycin containing drug regimens are difficult for the health services to deliver them to the patients in rural areas. Even with oral drugs INH + PAS or INH alone, drug regularity are 26.3% and 24.6%. The other technical limitation of treatment is the probability of increase in drug resistance due to the wide application of drug treatment which might be irregular. This has not been considered as enough justification for withholding treatment to the vast majority of patients, as its epidemiological and clinical significance in India are yet to be fully understood. The District TB Programme provides a firm organisational structure on the basis of which improvement can constantly be introduced for smooth functioning, constant supervision, proper orientation training and demonstration of the programme by the District TB Centre if necessary.

The organisational problems listed are: irregularity of drug intake and drug collection; their identification, default at drug collection, intake and remedial action, maintenance of records, check up while on treatment and follow up after completion of treatment. The paper suggests that regular collection could be taken as an index of regular drug intake. Defaulter actions could retrieve about 30% of the defaulters. Check up during treatment as well as follow up after treatment were found to be not acceptable to the patients due to a number of reasons. Training of staff to render services is also one of the biggest hurdles. The remedial measures are stressing tuberculosis as a community problem at the undergraduate and post graduate levels, training of the staff at every level of the programme and arrangement of seminars and group discussions with the administrators and medical personnel.

There is a wide spread prejudice among the staff of health centres that patients invariably prefer injection and it was felt by many health workers that streptomycin containing intermittent regimens would be more acceptable to rural patients. A study was carried out to find out the acceptability and applicability of an intermittent supervised drug regimen containing streptomycin 1 gm and INH 650 mgm once a week in a rural area as well as the regularity with which the rural folk took this treatment. Association between the observed regularity and factors like age, sex etc., was also analysed. 107 rural patients of tuberculosis, diagnosed at 5 taluk hospitals in Ananthapur district of Andhra Pradesh on the basis of sputum examination by direct smear and/or X-ray examination with the help of mobile X-rays, consented to treatment with intermittent regimen mentioned above. About half of them were new patients and the rest were old patients who were mostly regular on an earlier oral regimen. 94 of the above were available for analysis.

The regimen was found quite practicable in the sense that at no centre the study was interrupted or discontinued because of the inability of the health centre staff to give injection. If regularity is expressed as a proportion of patients who at any given time had taken the optimal amount of treatment (no. of injections), then 40 patients (42%) were found regular on the intermittent regimen, 36 patients were classified as lost and the remaining had 3 or less injections due and had not yet had the chance to become lost according to the definition adopted. Thus, the regularity of those accepting the regimen was quite low. There was very steep fall in regularity during the first 10 weeks of treatment, nearly a half of the total cases became irregular during the first 6 weeks. Beyond 4 months of treatment, patients who continued to attend centres regularly for treatment became negligible, thus pointing that injection was not a key variable in the treatment regularity of tuberculosis.