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.

The study group constitutes 86 ‘cases’ and 341 ‘suspects’ diagnosed in a TB prevalence survey. The area of the survey was under cover of the NTP for more than 20 years. The observed fate of these cases after five year was: dead 58.3%, culture negative 30% and culture positive 11.7%. Comparison of these rates with age standardised rates of ‘cases’ followed up after 5 years in an adjacent area, where control measures were not undertaken revealed that both these rates were not statistically different. The findings suggest that the same natural dynamics of TB as observed under the non-intervention situation, obtained in the study area as well, despite the latter being under the cover of NTP for so long.

Suspects, epidemiologically, proved to be a low priority group as the breakdown rate observed among them over five years was as low as 3.3%, again similar to the findings in the non-intervention area of a longitudinal survey.

A sociological enquiry revealed that cardinal symptoms of TB persisted even after five years in 65% of cases and 55% of suspects. Action taking behaviour indicated that more than half the patients, reported to GHS for remedial measures, while none of the ‘asymptomatics’ approached any health centre. These findings suggest that ‘symptoms’ are the driving force for patients to seek medical advice and the NTP still has the potential to bring these self-reporting cases within its network.