The present study attempts to understand the nature of the social and operational constraints affecting TB control and identify ways to remedy them. Such constraints, which are by their very nature intricate, demand prolonged, in-depth, field-based, qualitative and quantitative investigation, for their appreciation. The design of the present study allowed such an exhaustive inquiry and the composition of the study team facilitated it. The study had a ‘rural’ and an ‘urban’ component, and ‘users of health services’ and ‘providers of health services’ as sub-components. Distinctively, the investigation encompassed the lay people, the patients of TB, the public health care providers and the private health sector – all within the set-up of a district which is the peripheral administrative unit of the NTP. The study was conducted between 1991 and 1994 in Pune district of Maharashtra, at the time when TB was being rediscovered as a problem requiring urgent attention and action. Pune is one of the better developed districts of the most progressive state of Maharashtra in India. While this limits the generalizability of the study findings, there is little reason to believe that the constraints faced by the programme and its beneficiaries in areas with lower levels of development and poorer infrastructure, will be less.

Two hundred and ninety nine patients registered for treatment with the public health services-103 with rural PHC`s and 196 with urban TB clinics in Pune district were interviewed in order to understand social and operational determinants that influence treatment behaviour in lung TB. Detailed quantitative as well as qualitative information was elicited. The study showed that despite weak, if not missing, health educational inputs, patients' understanding of TB was satisfactory. Their preference for private doctors over public health services for TB, their frequent change of health providers for diagnosis as well as treatment, their poor treatment adherence despite knowledge of its ill-effects and their related actions perceived clearly as deleterious to their own good were influenced more by social, economic, and operational factors than by their self-destructive attitude and behaviour. The study concluded that it was the availability, affordability and acceptability of health facilities for TB-factors related primarily to the provider behaviour- that deserved greater and priority attention. Attempts at rectifying provider behaviour were likely to be more productive than those at disciplining patients.