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Tuberculosis programmes: Fragmentation or integration?
Tubercle and Lung Disease (1995) 76, I-3 03 1995 Pearson Professional Ltd
Tubercleand LungDisease
Tuberculosis programmes: fragmentation or integration? H. Hellberg
Finnish Lung Health Association, Helsinki, Finland
There is ongoing discussion in health circles about the °vertical' versus the 'horizontal' approach to diseases or health projects and programmes. Too often, these two approaches are proposed as being mutually exclusive. What is really needed in most cases, however, is a fruitful symbiosis of specialized knowledge and specific programme elements that go hand-in-hand with the efficient tttilization of an integrated health care system including functioning and community-based primary health care. Diagnosis and treatment of tuberculosis have also been drawn into this debate. There are experiences in many developing countries of not very successful isolated and totally separated tuberculosis activities, as well as attempts at routine integration with general health/ medical services leading to a weakening of the specific disease element. It has been shown that it is possible to deal with a single disease or health problem in vertical isolation with specialized single-purpose staff using special and earmarked resources. One may achieve good results in limited geographic areas as long as these special resources are available, but in most cases total coverage is impossible and even limited areas of responsibility tend to shrink or have to be abandoned due to lack of resources in the long run. This is especially true with a disease such as tuberculosis requiring prolonged treatment for the individual patient and long-term cormnitment on the part of the community. The temptation to use the vertical and single disease approach leads to fragmentation of effort, inefficient use of resources and gives the popuDr Hellberg was formerly with the World Health Organization (WHO), Geneva, participating in the developmentof primary health care concepts and programmes, including the Alma-Ataconference on primary Health Care (1978). He was also WHO Headquarters Coordinator of Health for All by the Year 2000 activities (1981-86) and Finnish Governmentrepresentative to the World Health Assemblies 1975-81 and the WHO Executive Board (1976-78). He is currently a consultant for the Finnish Lung Health Associationand teaches on the role of primary health care in tuberculosis control in the International Tuberculosis Courses of IUATLD in Arusha, Tanzania. Correspondenceto: HSkanHellberg MD, DTM&H, Finnish Lung Health Association, Sibeliuksenkatu l 1 A 1, 00250 Helsinki, Finland.
lation and the health workers a distorted view of health and disease in a community. In developing countries the different specialized vertical teams and their vehicles visit the same conmmnity, village or township on separate days of the week waving their respective flags of identity and technical competence. Tuberculosis on Monday, Maternal and Child Health on Tuesday, Immunization on Wednesday, etc (Fig. 1). The separate triangles symbolize the folly of fragmentation and the irresponsible use of resources. In many cases diminishing resources, both human and material, make it impossible to continue such a fragmented approach. As the vertical specialized activity gradually weakens as visits to the community become less and less frequent and more irregular, the battle will soon be lost, and in the case of tuberculosis the epidemiological situation deteriorates. This deterioration is further enhanced if the responsibility for tuberculosis is part of the overall task of controlling all communicable diseases with little or no special knowledge or experience in tuberculosis and with a lack of any earmarked resources. This is particularly disastrous for the fight against tuberculosis where curative treatment is the best prevention. The general approach to many communicable diseases correctly emphasizes preventive measures other than drug treatment. In an integrated programme this may put tuberculosis with the emphasis on treatment in a less favorable position, i.e., leaving too few resources to buy a guaranteed supply of antituberculosis drugs. If these few drugs are incorrectly used because of weak or absent tuberculosis expertise the results may be disastrous. Another sad result is that the integrated approach gets a bad reputation, and one may again try to compensate by developing a vertical approach which does not succeed due to the reasons mentioned above. The result is evident in many countries. What might then be the solution? Is it possible to combine specialization and integration? There are examples of national tuberculosis prograrrunes with a functioning combination of special leadership input based on experience with the disease and availability
Tubercle and Lung Disease
Fig. 1-Fragmented approach to disease control at all levels.
of earmarked resources for tuberculosis control, utilized within a general health care system based on a primary health care approach. This kind of functioning and coordinated approach needs to be developed wherever one wants to embark seriously on the control of tuberculosis. Figure 2 shows how the same population (the base of the triangle) is reached in an integrated, horizontal fashion by the local and the district level health workers, who are supported by vertical interests at regional and national levels. At the national level there is a tuberculosis coordination unit waving the flag of specialized knowledge and with access to resources specifically allocated for tuberculosis control. This unit is, of course, related to other parts of the health service but has its own 'flag' and administrative identity. At the regional level the integration and coordination goes further but a regional tuberculosis coordinator is needed. The relationship to other elements of the regional general health services is closer than at the national level, but a degree of special identity should be retained with regard to drugs and transport facilities. In the district, the integration goes further, with more involved leadership for the general health services, but using a district tuberculosis coordinator with specialized knowledge. In most circumstances multipurpose health workers are the implementing agents. When the number of cases decreases there is a temptation to stop using workers with special knowledge
and experience at district (and perhaps regional) level. This has happened with some successful malaria programmes. The specialized workers were withdrawn at the critical time when good results should have been consolidated and epidemiological vigilance kept up. A resurgence of malaria has been the result, and the same may happen to tuberculosis if continued vigilance is neglected. It is understandable that there will be pressure to use multipurpose workers in dispensaries, health posts and health centres. This is natural, but it is therefore all the more important to provide proper support and supervision for priority health problems as well as for the integrated approach closer to the community level. This is the task of the tuberculosis coordinator. It may be difficult for health workers to realize that the role and identity of those dealing with tuberculosis will be different at the national level (specific and controlling resources), the regional level (applying specific knowledge, but to some extent sharing resources), and the district level where both special experience/knowledge and resources are shared. For the people in the community, however, life is an integrated whole and trained health workers must not split up their daily routine through a fragmented approach to health and disease. A disease with important social dimensions such as tuberculosis cannot be tackled res-
National level
. Regional level
D i s t r i c t and local level Fig. 2---Integrationof specializedknowledge at different levels of operation.
Tuberculosis programmes: fragmentation or integration?
ponsibly and in the required longer term, unless we learn to develop the appropriate models of integration, while at the same time applying special knowledge and resources related to the disease. One must then be ready to discard the fragmented approach (Fig. 1) and the ready to develop 'the crown of life' approach (Fig. 2). The latter is more complex and requires much negotiation, supportive supervision and
continuous concern for functioning human and administrative relationships. Refusing the simplified and mutually exclusive vertical or horizontal approaches, a national tuberculosis programme needs to accept the complex method of special professional competence with earmarked resources permeating the different levels of the general health care system in an integrated manner.
1995 ANNUAL MEETING OF THE IUATLD
SYMPOSIUM ON TUBERCULOSIS
Palais des Congr~s, Paris 9-12 September 1995
2nd June 1995 Conference Centre Royal College of Physicians Edinburgh
Scientific programme Plenary sessions, symposia, poster presentations and post-graduate courses
Main topics Nursing in tuberculosis care Model tuberculosis programme Resistance to antituberculosis drugs HIV and tuberculosis Childhood and tuberculosis Childhood pneumonia Tuberculosis and migration Tuberculosis in animals Tobacco prevention Asthma New diagnostic techniques
TBkills more than 2 million people annually in the developing world and after decades of decline, rates of infection are rising again in the industrialized world, including the UK. This symposium is designed to raise awareness of current developments in the prevalence, treatment and prevention of TB, • TB: The International and Historical Perspective Sir John Crofton • TB in Scotland Dr A. G, Leitch • TB in Immigrants Dr L. P. Ormerod • Laboratory Diagnosis of TB Dr Brian Watt • HIV and TB Dr R. F. Miller • BCG: Present and Future Dr Gavin Boyd ° TB: Prevention and Health Education Dr F. Festenstein
Registration Fee: £35
Languages English and French
CHEST,HEART STROKESCOTLAND
Deadline for submission of abstracts for posters 30th April 1995
a medical charity
Further information
For a registration p a c k please contact:
For general organization, registration, abstract forms and accommodation information, write to
SOCFI 14 rue Mandar 75002 Paris Tel: (+33-1) 42 33 89 94 Fax: (+33-1) 40 26 04 44 i
3
k.,
Chief Executive CHS Scotland 65 North Castle Street Edinburgh EH2 3LT Tel: 0131 225 6963 Fax: 0131 2206313
Tubercleand LungDisease
Tuberculosis programmes: fragmentation or integration? H. Hellberg
Finnish Lung Health Association, Helsinki, Finland
There is ongoing discussion in health circles about the °vertical' versus the 'horizontal' approach to diseases or health projects and programmes. Too often, these two approaches are proposed as being mutually exclusive. What is really needed in most cases, however, is a fruitful symbiosis of specialized knowledge and specific programme elements that go hand-in-hand with the efficient tttilization of an integrated health care system including functioning and community-based primary health care. Diagnosis and treatment of tuberculosis have also been drawn into this debate. There are experiences in many developing countries of not very successful isolated and totally separated tuberculosis activities, as well as attempts at routine integration with general health/ medical services leading to a weakening of the specific disease element. It has been shown that it is possible to deal with a single disease or health problem in vertical isolation with specialized single-purpose staff using special and earmarked resources. One may achieve good results in limited geographic areas as long as these special resources are available, but in most cases total coverage is impossible and even limited areas of responsibility tend to shrink or have to be abandoned due to lack of resources in the long run. This is especially true with a disease such as tuberculosis requiring prolonged treatment for the individual patient and long-term cormnitment on the part of the community. The temptation to use the vertical and single disease approach leads to fragmentation of effort, inefficient use of resources and gives the popuDr Hellberg was formerly with the World Health Organization (WHO), Geneva, participating in the developmentof primary health care concepts and programmes, including the Alma-Ataconference on primary Health Care (1978). He was also WHO Headquarters Coordinator of Health for All by the Year 2000 activities (1981-86) and Finnish Governmentrepresentative to the World Health Assemblies 1975-81 and the WHO Executive Board (1976-78). He is currently a consultant for the Finnish Lung Health Associationand teaches on the role of primary health care in tuberculosis control in the International Tuberculosis Courses of IUATLD in Arusha, Tanzania. Correspondenceto: HSkanHellberg MD, DTM&H, Finnish Lung Health Association, Sibeliuksenkatu l 1 A 1, 00250 Helsinki, Finland.
lation and the health workers a distorted view of health and disease in a community. In developing countries the different specialized vertical teams and their vehicles visit the same conmmnity, village or township on separate days of the week waving their respective flags of identity and technical competence. Tuberculosis on Monday, Maternal and Child Health on Tuesday, Immunization on Wednesday, etc (Fig. 1). The separate triangles symbolize the folly of fragmentation and the irresponsible use of resources. In many cases diminishing resources, both human and material, make it impossible to continue such a fragmented approach. As the vertical specialized activity gradually weakens as visits to the community become less and less frequent and more irregular, the battle will soon be lost, and in the case of tuberculosis the epidemiological situation deteriorates. This deterioration is further enhanced if the responsibility for tuberculosis is part of the overall task of controlling all communicable diseases with little or no special knowledge or experience in tuberculosis and with a lack of any earmarked resources. This is particularly disastrous for the fight against tuberculosis where curative treatment is the best prevention. The general approach to many communicable diseases correctly emphasizes preventive measures other than drug treatment. In an integrated programme this may put tuberculosis with the emphasis on treatment in a less favorable position, i.e., leaving too few resources to buy a guaranteed supply of antituberculosis drugs. If these few drugs are incorrectly used because of weak or absent tuberculosis expertise the results may be disastrous. Another sad result is that the integrated approach gets a bad reputation, and one may again try to compensate by developing a vertical approach which does not succeed due to the reasons mentioned above. The result is evident in many countries. What might then be the solution? Is it possible to combine specialization and integration? There are examples of national tuberculosis prograrrunes with a functioning combination of special leadership input based on experience with the disease and availability
Tubercle and Lung Disease
Fig. 1-Fragmented approach to disease control at all levels.
of earmarked resources for tuberculosis control, utilized within a general health care system based on a primary health care approach. This kind of functioning and coordinated approach needs to be developed wherever one wants to embark seriously on the control of tuberculosis. Figure 2 shows how the same population (the base of the triangle) is reached in an integrated, horizontal fashion by the local and the district level health workers, who are supported by vertical interests at regional and national levels. At the national level there is a tuberculosis coordination unit waving the flag of specialized knowledge and with access to resources specifically allocated for tuberculosis control. This unit is, of course, related to other parts of the health service but has its own 'flag' and administrative identity. At the regional level the integration and coordination goes further but a regional tuberculosis coordinator is needed. The relationship to other elements of the regional general health services is closer than at the national level, but a degree of special identity should be retained with regard to drugs and transport facilities. In the district, the integration goes further, with more involved leadership for the general health services, but using a district tuberculosis coordinator with specialized knowledge. In most circumstances multipurpose health workers are the implementing agents. When the number of cases decreases there is a temptation to stop using workers with special knowledge
and experience at district (and perhaps regional) level. This has happened with some successful malaria programmes. The specialized workers were withdrawn at the critical time when good results should have been consolidated and epidemiological vigilance kept up. A resurgence of malaria has been the result, and the same may happen to tuberculosis if continued vigilance is neglected. It is understandable that there will be pressure to use multipurpose workers in dispensaries, health posts and health centres. This is natural, but it is therefore all the more important to provide proper support and supervision for priority health problems as well as for the integrated approach closer to the community level. This is the task of the tuberculosis coordinator. It may be difficult for health workers to realize that the role and identity of those dealing with tuberculosis will be different at the national level (specific and controlling resources), the regional level (applying specific knowledge, but to some extent sharing resources), and the district level where both special experience/knowledge and resources are shared. For the people in the community, however, life is an integrated whole and trained health workers must not split up their daily routine through a fragmented approach to health and disease. A disease with important social dimensions such as tuberculosis cannot be tackled res-
National level
. Regional level
D i s t r i c t and local level Fig. 2---Integrationof specializedknowledge at different levels of operation.
Tuberculosis programmes: fragmentation or integration?
ponsibly and in the required longer term, unless we learn to develop the appropriate models of integration, while at the same time applying special knowledge and resources related to the disease. One must then be ready to discard the fragmented approach (Fig. 1) and the ready to develop 'the crown of life' approach (Fig. 2). The latter is more complex and requires much negotiation, supportive supervision and
continuous concern for functioning human and administrative relationships. Refusing the simplified and mutually exclusive vertical or horizontal approaches, a national tuberculosis programme needs to accept the complex method of special professional competence with earmarked resources permeating the different levels of the general health care system in an integrated manner.
1995 ANNUAL MEETING OF THE IUATLD
SYMPOSIUM ON TUBERCULOSIS
Palais des Congr~s, Paris 9-12 September 1995
2nd June 1995 Conference Centre Royal College of Physicians Edinburgh
Scientific programme Plenary sessions, symposia, poster presentations and post-graduate courses
Main topics Nursing in tuberculosis care Model tuberculosis programme Resistance to antituberculosis drugs HIV and tuberculosis Childhood and tuberculosis Childhood pneumonia Tuberculosis and migration Tuberculosis in animals Tobacco prevention Asthma New diagnostic techniques
TBkills more than 2 million people annually in the developing world and after decades of decline, rates of infection are rising again in the industrialized world, including the UK. This symposium is designed to raise awareness of current developments in the prevalence, treatment and prevention of TB, • TB: The International and Historical Perspective Sir John Crofton • TB in Scotland Dr A. G, Leitch • TB in Immigrants Dr L. P. Ormerod • Laboratory Diagnosis of TB Dr Brian Watt • HIV and TB Dr R. F. Miller • BCG: Present and Future Dr Gavin Boyd ° TB: Prevention and Health Education Dr F. Festenstein
Registration Fee: £35
Languages English and French
CHEST,HEART STROKESCOTLAND
Deadline for submission of abstracts for posters 30th April 1995
a medical charity
Further information
For a registration p a c k please contact:
For general organization, registration, abstract forms and accommodation information, write to
SOCFI 14 rue Mandar 75002 Paris Tel: (+33-1) 42 33 89 94 Fax: (+33-1) 40 26 04 44 i
3
k.,
Chief Executive CHS Scotland 65 North Castle Street Edinburgh EH2 3LT Tel: 0131 225 6963 Fax: 0131 2206313