During last two decades, the health care delivery system has undergone several changes. The implementation of the concept of Primary Health Care and of the Multi Purpose Health Workers (MPWs) Scheme can be utilised to improve both Case-finding and case holding activities of the District Tuberculosis Programme. A study was undertaken by National Tuberculosis Institute (NTI) to obtain a profile of work of MPWs, observe their work on time and motion analogy and to ascertain output of tuberculosis services and other works. The study was carried out in a contiguous area of 6 PHCs of a district. The work of 16 MPWs was observed by a Social Investigator of NTI who accompanied them during a day's work; one month period was selected as reference period. 160 MPWs were asked to give details of their activities through self administered questionnaire and records of the six PHCs were studied in terms of output of the services.

On an average a MPW travelled 15 kms, spent 4 hours in the village, visited 70 homes; Of them, 25% were locked. The time spent on different activities during home visits were 34% for minor ailments, 26% on malaria, 12% on family welfare and 11% on tuberculosis. Profile of activities carried out on a randomised day were, 77.5% did not perform any anti tuberculosis activities. Those who did anti tuberculosis work identified 4 symptomatics, prepared two smears and followed up 13 patients. The highest performance was with regard to Family Welfare (68%) and treatment of ailments (64%). As per the opinion of MPWs tuberculosis was 7th, 8th and 9th rank, malaria was lst and 3rd and family welfare was 1st and 2nd. As per the actual output of work from the PHC records, anti malaria (70%) and minor treatment had the maximum performance and family welfare averaged, as only 35 of the eligible couples were registered. Findings suggest that tuberculosis was given lower priority in terms of all the three points i.e., actual performance, profile of work of MPW, actual day's work of MPW and diverse health activities among rural population. Integration of tuberculosis at periphery needs more important considerations.

This is a conceptual account of the District Tuberculosis Control Programme. The District Tuberculosis Programme (DTP) was formulated by the National Tuberculosis Institute in 1962 to form the basis of a community-wide programme to deal with the challenge of a large, predominantly rural tuberculosis problem in the country. The limited resources in the form of funds, trained personnel and equipment, made it necessary that the programme be simple, easy to apply and widely acceptable.

The DTP includes provision for tuberculosis Case-finding, treatment and prevention throughout the district from the health institutions in an integrated manner. Case-finding is carried out among the symptomatics attending the health institutions primarily by sputum examination and treatment is offered on ambulatory domiciliary basis. District Tuberculosis Centre (DTC) represents the pivot around which the integrated DTP revolves. DTC takes up all the responsibilities in respect of the programme on behalf of the District Health Authority. It undertakes planning, implementation, coordination and supervision of the DTP in the entire district besides offering the usual diagnosis and treatment service to the population, under its direct care. Health institutions other than DTC which participate in the DTP are called "Peripheral Health Institutions" (PHIs). These are categorised into "Microscopy Centres" and "Referring Centres" depending upon possession of microscope or otherwise. Both categories are full-fledged "Treatment Centres". Sputum examination is offered to all chest symptomatics reporting at "Microscopy Centres" and if found positive for AFB the patient is motivated and put on treatment immediately. DTC maintains the important "District TB Case Index" and offers "referral" X-ray examination to the sputum smear negative symptomatics referred by the "Referring Centres". One BCG Vaccination Team also works under DTC. There is one DTC in a district and the already existing TB clinics become just one of the PHIs under one DTC. Key staff consisting of a District Tuberculosis Officer (DTO), a Treatment Organiser (TO), a Laboratory Technician (LT), an X-ray Technician (XT), BCG Team Leader and a Statistical Assistant (SA) are required to provide service from the DTC and to organise the programme of Case-finding and treatment in an integrated manner throughout the district from all available institutions of General Health Services.

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.