Evaluation of District Technical Support Teams (DTSTs) in the
state of Bihar
19th February 2006 – 2nd March 2006
(Final Version)
by
1.
Dr. D. Gopinath, ,
Professor, Department of Community Medicine,
M.S. Ramaiah Medical College
MSR Nagar, Bangalore – 560 054
2.
Dr. B. Sekar
Joint Director,
Central Leprosy Teaching &
Research Institute,
Chengalpet- 603 001
3.
Dr. Mani Mozhi
Medical Consultant
AIFO, Bangalore
4.
Dr. K. Lalitha
Lecturer
M.S. Ramiah Medical College
MSR Nagar, Bangalore – 560 054
DTST Evaluation Report – Bihar (Final Version)
1
TABLE OF CONTENTS
List of Abbreviations
1) Executive summary
a) Background
b) Major findings
c) Future role of DTSTs
d) Summary of recommendation
2) Introduction
3) Background information on the general health system
4) Background information on leprosy health services
5) Background information on the DTST
6) Epidemiological trend in the state and also in the selected districts
7) Methodology adapted for the evaluation
8) Results of Evaluation
9) Recommendations
10) Future strategy to be followed
11) Acknowledgements
12) Annexures
i) --------ii) --------
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List of Abbreviations
ANM – Auxiliary Nurse midwife
APHC- Additional PHC
BI - Bacteriological Index
BPHC- Block PHC
CS – Civil Surgeon
DFIT- Damien Foundation India Trust
DLO- District Leprosy Officer
DLS- District leprosy Society
DN- District Leprosy Nucleus
DTST- District Technical Support Team
GHW - General Health Worker
GHS- General Health System
GOI - Governement of India
HCF- Health Care Facility
IEC - Information, Education and Communication
IPC – Inter-personal communication
ILEP - International Federation of Anti-Leprosy Associations
MB - Multibacillary
MB% - Multibacillary proportion (among new cases)
MDT- Multidrug Treatment
MoH -Ministry of Health
NGO - Non-Governmental Organisation
NLEP - National Leprosy Eradication Programme
NLR - Netherlands Leprosy Relief
PB - Paucibacillary
PHC - Primary Health Centre
HSC - Health Sub Centre
POD- Prevention of Disabilities
RFT - Released From Treatment
SIS- Simple Information System
ST - Sensory Test
TLM - The Leprosy Mission
WHO - World Health Organisation
DTST Evaluation Report – Bihar (Final Version)
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1. EXECUTIVE SUMMARY
1.1 Background
The Government of India continued its National Leprosy Eradication
Programme beyond December 2005 , the target date for achieving elimination,
through an integrated approach, which was laid down in a strategic plan for the
years 1st January 2005 to 31st March 2007.
The ILEP Members active in India have participated in leprosy control
activities in close collaboration with Government of India and have offered their
support Strategic Plan of NLEP. Accordingly an MOU was signed between GOI
and ILEP agencies with the aim to provide assistance to those activity areas that
are crucial to sustain effective, integrated leprosy services within the frame work
of strategic plan of NLEP. ILEP provides technical support through District
Technical Support Teams (DTSTs) at peripheral level to sustain the
achievements of the NLEP and to facilitate the establishment and maintenance
of adequate quality integrated leprosy services.
The DTSTs were established and the purpose of the teams was revised to
strengthen the integration process. The placement of DTSTs was guided by the
revised DTST guidelines formed in November 2004. It was proposed that an
evaluation would be carried out to review the requirement and placement of
DTSTs and to recommend a set of criteria for placement of DTSTs in the country.
The evaluation was carried out from 19th February to 2nd March 2006 in Bihar
state. Two teams were formed. One team visited the districts of Sitamarhi and E.
Champaran and the other visited Begusarai and Patna. The evaluators were
assigned to bring out the need of Technical support in different states, where
DTSTs were operational and also the suitable mode of technical support either in
the form of DTST or any other means to the district and state level health
programmes.
The suggested criteria would be further discussed with Central Leprosy
Division for placement of DTSTs.
1.2 Major findings
1.2.1 Integration Status
-
All the Health care facilities are diagnosing, registering and initiating MDT.
DTST Evaluation Report – Bihar (Final Version)
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However, the diagnosis and management of complicated cases are not
adequate. The medical officers are registering cases when they are confident
about the diagnosis: doubtful cases are confirmed and registered cases are
validated and counseled by the teams on the counseling days. It was observed
that the counseling was carried out by the DTST team and not by the identified
person of the District Nucleus. A sample of validated cases by DTST team was
verified by the evaluation team and was found correct.
1.2.2 MDT management
-
Indent of MDT for a district is computed by DLO and sent to CS office for
procurement of drugs from central depot. Based on the demand, the drug
supply is made by the depot to the CS office. Indents from the PHCs are
directly made to the CS office and the same is supplied. At PHC, after
confirmation and registration, first dose of MDT is started and the rest of
the doses are provided at the HSC by the ANMs. However, inspection of
the stock revealed that inadequate stock of MB (A) in all health facilities
and MB(C) in some cases and excess of PB (A) in some health facilities.
1.2.3 Simple Information System
-
Registers are maintained and updated at the PHC. Collection and
compilation of information as per the SIS guidelines is found to be
satisfactory. Monthly Progress Reports as per SIS format are prepared by
the NLEP staff and sent to the district and further to the State. The reports
are analysed, interpreted at the State level by the SLO/NLEP Coordinator/
DTST Coordinators. However, the analysis of the indicators are not done
at the PHC and the district level and not utilized for the programme
management.
1.2.4 Monitoring and Supervision:
-
-
Monitoring and Supervision at the PHC and Health Sub-Centre levels are
carried out by the DTST’s – Contribution of the DLO/District Nucleus is
found inadequate. Interpretation of the indicators is not carried out
PHC/District levels.
Computation of the indicators (PR/ NCDR/ MB prop/ Child proportion) is
being carried out by the DTST’s and not by the NLEP staff at the PHC
level
1.3 Future role of DTSTs:
The Monitoring, Evaluation and Supervision have to be strengthened utilizing
the manpower and resources, available at the district and PHC level.
DTST Evaluation Report – Bihar (Final Version)
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Complications of reactions and POD care are not adequately managed at the
PHC and district level.
With the declining prevalence of Leprosy, there is need for effective referral
system to be in place for management of POD and rehabilitation to be given
special attention to the individuals already affected.
The District Leprosy Nucleus is constituted with the participation of different
officials at the district level. These members must be within the same site so that
they can interact with each other and plan their visit programmes.
The District nucleus is in the infancy stage and currently they are defunct.
District Leprosy Nucleus need to be strengthened and this may probably be the
one of the focus area for DTSTs in future to concentrate in enabling the DLN to
become functional and be effective and gradually become independent in the
programme management.
Since the DLN is in transition of taking over the role of DTST, before the
support of DTST is withdrawn, there is a strong need for capacity building of the
DLN team to be in the streamline of the integration process
1.4 Summary of recommendation
The integration at grass root level is highly satisfactory but at the level of
primary health centre, the capacity of the Medical officers in charge of these
centres needs to be further strengthened in the programme implementation and
management. This may be one area where DTST can support.
Integration at the secondary and tertiary level appeared to be incomplete.
The evaluation team felt continued support of DTST is desirable to strengthen
the integration at the secondary and tertiary level.
The present form of DTST placed at district level may be relocated and it can
operate at Zonal level. Each DTST can take up 4 – 5 districts under their care.
DTST can spend four days in each district. Out of four days, one day they can
spend in the DLO office for management of complications and other related
problems and for the rest of 3 days, they can visit 4 –5 problematic PHCs along
with District Leprosy Nucleus, On the other days the District Leprosy Nucleus can
plan their visit to PHCs for counseling on their own utilizing the budget allotted to
them for that specific reason.
DTST should clearly emphasize their facilitating and support role and there is
a need for development of withdrawal indicators.
DTST Evaluation Report – Bihar (Final Version)
6
2. INTRODUCTION
2.1. Background
The Government of India being committed to eliminate Leprosy i.e. prevalence
rate less than 1 case per 10,000 inhabitants at national level by 31 st December
2005, however continued its National Leprosy Eradication Programme through
an integrated approach beyond December 2005, which was laid down in a
strategic plan for the years 1st January 2005 to 31st March 2007.
The ILEP Members active in India are offering their support in partnership with
Government of India to Strategic Plan of NLEP of Government of India and
accordingly an MOU was signed between GOI and ILEP agencies with the aim to
provide assistance to those activity areas that are crucial to sustain effective,
integrated leprosy services within the frame work of strategic plan of NLEP of
Government of India.
ILEP Members supporting NLEP by facilitating and strengthening the process of
integration of leprosy services into the General Health Care system. The
following areas of activities under NLEP were to be supported / implemented:
1. Support to sustained capacity building of GHC staff
2. Provision of technical support – National, State and district level
3. Strengthening of an adequate referral system
4. Establishing Reconstructive Surgery Services in Government Medical
Colleges
5. Special attention to urban leprosy control
6. Participation in community education and advocacy
7. Joint monitoring and evaluation
8. Support to (operational) research
9. Support to Community Based Rehabilitation
With reference to the above, ILEP Members will also provide technical support
through District Technical Support Teams (DTSTs) at peripheral level to sustain
the achievements of the NLEP and to facilitate the establishment and
maintenance of adequate quality integrated leprosy services.
The DTSTs were established and the purpose of the teams was revised to
strengthen the integration process. The placement of DTSTs was guided by the
revised DTST guidelines formed in November 2004. It was proposed that an
evaluation would be carried out to review the requirement and placement of
DTSTs and to recommend a set of criteria for placement of DTSTs in the country.
The suggested criteria would be further discussed with Central Leprosy Division
for placement of DTSTs.
The evaluation was carried out with the intention of bringing out the need for
Technical support in different states, where DTSTs are operational. The study
DTST Evaluation Report – Bihar (Final Version)
7
would also bring out suitable forms of technical support either in the form of
DTST or any other means to the district and state level health programmes. In
the event of identifying DTSTs as the main form of technical support, the study
will advise on the placement and distribution of DTSTs.
3. BACKGROUND INFORMATION ON THE GENERAL HEALTH
SYSTEM
General health service at the most peripheral level is managed by Multipurpose
health worker, male and female, one for every 10000 to 15000 population. It is
usually the female health worker otherwise called Auxiliary Nurse and Midwife
(ANM) who implements all the major public health programmes. She is assisted
in some districts by Anganawadi worker, one for every 1000 population. For
every 4 ANMs there is a supervisor called Lady Health Visitor. For every 100000
to 200000 population there is a Primary Health Centre manned by 4 Medical
Officers, Staff nurse, pharmacist and other ancillary staff. One also finds
Additional PHCS sometimes 2 to 4 for every PHC. But most often these APHCs
are non functional and they are used as Subcentres. All the public health
programmes are controlled by the Civil Surgeon who is assisted by a Assistant
programme officer, one for each major programme. The Civil Surgeon is the Vice
Chairman of the District Health Society which is under the Chairmanship of the
District Collector. The state has 38 districts, each with an average population of
1.5 to 3 million. All the health programmes in the state are under the control of
State health Society. The health commissioner is the chairman of the society and
the Director of health services is the Secretary. He is assisted by programme
officers, one for each major programme.
4. BACKGROUND
SERVICES
INFORMATION
ON
LEPROSY
HEALTH
Leprosy programme like any other health programme is planned, implemented
and monitored in the state by the State health society which is assisted by a
programme officer for leprosy called State Leprosy Officer. He is assisted at the
state level by NLEP consultant and DTST coordinator and at the District level by
the District leprosy Officer and the DTST. There are also zonal NLEP
coordinators (two) to assist the SLO at the zonal level. Below the district leprosy
control is integrated into general health. District nucleus comprising of DLO, MO
and paramedical workers/supervisors has been formed in 30 districts. Majority of
the members of DN have been trained.
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5. BACKGROUND INFORMATION ON THE DTST
District Technical Support team concept was evolved in 1996. At the time the
state had severe problems in implementing leprosy control- inadequate
infrastructure, untrained staff, geographical problems of accessibility, lack of
supervision and monitoring. It was decided that one of the means of rectifying the
situation was to import expert teams from outside the state and place them in the
districts to support the local staff in implementing the leprosy control activities as
per the expectations of the Government. Initially teams were placed by DFIT and
WHO and later the districts were divided among 4 ILEP agencies- DFIT, LEPRA,
NLR and TLMI. Each team consisting of a Medical Officer and a Supervisor
covered one or two districts. At the moment DFIT covers 22 districts, LEPRA 10
districts, NLR 5 and TLMI one. The teams are coordinated by a DTST
coordinator placed in Patna.
6. EPIDEMIOLOGICAL TREND IN THE STATE AND ALSO IN THE
SELECTED DISTRICTS
Trend of Leprosy in Bihar State (1996 – 2006(Feb.)
Year
NCDR
PR
MB
Deformity
Child
1996-97
10.3
10.6
31.9
5.8
13.3
1997-98
11
8.5
34.1
4.8
13.5
1998-99
28.8
14.3
33.5
4.6
9.8
1999-00
16.1
14.3
37.2
3.1
11.1
2000-01
12.7
9.7
35.8
2.1
14.5
2001-02
13.4
10.6
33.7
2.2
15
2002-03
11.1
8.9
31.6
1.4
15.7
2003-04
7.3
4.9
31.2
0.9
15.6
2004-05
4.5
1.8
29.9
0.9
18.4
2005-06
2.6
1.3
35.5
1.4
15.9
(Feb)
Systematic Leprosy Control activities actually started with the
first Modified Leprosy Elimination Campaign (MLEC) in 1998.
The programme had little attention before that. Integration was
done in 2001. Between 1998 and 2005 the state had carried out
four MLECs and two BLACs. This was responsible for quite a
large number of cases getting detected. Validation of new cases
was done twice during the period and it was reported that Wrong
DTST Evaluation Report – Bihar (Final Version)
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Diagnosis and Re-registration accounted for 15% of new cases
detected.
New case detection showed considerable reduction from 2003
onwards. This was mainly due to cessation of all active case
detection activities. Reduction in prevalence was due to vast
improvement in registration practice as well as reduction in new
case detection.
Less than 40% MB cases, very low deformity among child cases
and relatively significant proportion of child cases among the
new indicate that though case detection has come down it is yet
to stabilize. We may see a NCDR of around 2 for some time
before it shows a decline.
7. METHODOLOGY ADAPTED FOR THE EVALUATION
7.1.1 The Main Objectives of the evaluation are:
(i).
Assess the contribution of DTSTs to the integration process in the states
and districts where they are functioning.
(ii).
Identify the needs for future support
7.1.2. The Specific Objectives are:
(i).
Contribution of DTSTs in capacity building of the GHC staff in:
(Refer monitoring indicators of DTST – Annexure – II)
- Diagnosis, treatment of disease and its complication
- Record maintenance and report generation
- Drug supply management,
- Supervision and monitoring
(ii).
Identify the needs of NLEP at present and in future
(iii).
Identify the form and content of ILEP support at different levels
(iv).
Identify the quantum, composition and distribution of DTSTs, if the support
is needed in the form of DTSTs.
7.2 The ILEP agencies currently working in the Bihar are)
1. Damien foundation India Trust (DFIT)
2. Netherlands Relief Association (NLR)
DTST Evaluation Report – Bihar (Final Version)
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3. Lepra
4. TLMI
7.3 . Evaluation Team
1.
Dr. D. Gopinath, ,
Professor, Department of Community Medicine,
M.S. Ramaiah Medical College
MSR Nagar, Bangalore – 560 054
2.
Dr. B. Sekar
Joint Director,
Central Leprosy Teaching Research Institute,
Chengalpet – 603 001
3.
Dr. Mani Mozhi
Medical Consultant
AIFO, Bangalore
4.
Dr. K. Lalitha
Lecturer/ Asst. Professor
M.S. Ramiah Medical College
MSR Nagar, Bangalore – 560 054
7.4. Programme of the visit
The Evaluation was carried out between the 19th February to 2nd March 2006.
Team I: Dr. D.Gopinath & Dr.B. Sekar visited the districts of Sitamarhi and
E. Champaran.
Team II: Dr. Mani Mozhi & Dr. Lalitha K. visited Begusarai and Patna.
A detailed programme can be found in Appendix I.
7.5. Method of Reporting
The major findings, conclusion and recommendations of the evaluation were
discussed on the 2nd March 2006 during the debriefing session in which the State
health authorities, Project co-ordinator, Representatives of (DFIT/NLR/ TLM/
Lepra India) were represented. This report presents the findings and conclusion
of the evaluation in more details, under different headings.
7.6.
Assessment Method
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7.6.1. Key Informant Interviews & Discussion:
- Dr. Raman, Deputy Director, State government of Bihar
- Dr. Shukla, State coordinator NLEP, Bihar
- Dr. Sudhir Kumar, State Leprosy Officer
- Dr.Bhimsaria, State health society, Bihar
- Civil surgeons (CDMOs) of the selected districts
- DLOs and other member of District nucleus team of selected district
- PHC Medical officers of selected Block PHCs & Additional PHC
- Health Supervisors of selected PHCs
- Multipurpose Workers of selected PHCs
- Doctor in charge of District Hospital
- Dr. Bishwanath, DTST state coordinator, Bihar
- DTST Medical Officers and NMSs (of the selected districts)
- Leprosy Patients ( 5 patients from each selected block )
- Community Members
7.6.2. Review of documents such as Progress reports of the DTST and
other relevant documents.
Review of Records & Registers
1) At state level:
i. Action Plan
ii. MOU.
iii. Annual and monthly progress reports
iv. Organogram of health services
v. Epidemiological trend in the last ten years- PR,
NCDR, MB/PB cases, Child cases, Deformity
cases
2) At District level:
i. Action Plan
ii. Annual and monthly progress report
iii. SIS guidelines
3) Block PHC/ APHC
i. Review of OPD register in the past 6 months
ii. Master register
iii. MDT stock register
iv. Patient card
v. Monthly report
1. SIS guidelines availability
2. Patient card
3. Treatment register
4. Monthly report
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4) DTST:
i. MOU
ii. Action plan
iii. Monthly reports
7.7. Calendar of events
1. Briefing sessions on the 24th January 2006 with Director of Health
Services, SLO, Other State Government authorities.
2. Discussions with DTST Project co-ordinator and other staff of DTST head
quarters in Patna.
3. Discussions with Health authorities at district levels (CMOH and DLO) and
health staff at all level.
4. Discussions with DTST Medical Officer and NMS.
5. Discussion with District Magistrate wherever available.
6. Analysis of patient records, registers, reports (SIS) and activities of
general health staff and DTSTs.
7. Observation of activities and general health structures during visits to
health facilities.
8. Exclusive visits to villages to meet community members and patients to
records their views.
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8. RESULTS OF EVALUATION
8.1. Integration Status
-
-
-
-
-
All Health care facilities are diagnosing, registering and initiating MDT
Diagnosis and management of complications are not adequate
Diagnosis and registration of leprosy cases is carried out on all days
MDT is provided on all working days
Most of the Health Sub Centres suspect and refer patients to the PHC for
diagnosis. ANMs are well aware of their job function and are doing
excellent job.
Medical officers are registering the cases - they are confident and are
nitiating the treatment immediately. There is need for more motivation for
further involvement
Quality of the case diagnosis was also found to be adequate both by the
observation of the reports on validation of cases available in the records
and also by the validation carried out by the Evaluation Team during their
visit.
Doubtful cases are confirmed and registered cases are validated and
counselled on the counselling days. How ever it was observed that
counselling is carried out by the DTST and not by the identified person of
the District Nucleus
On completion of the treatment, RFT procedures are completed in majority
of the cases.
Availability of job functions chart and SIS guidelines was lacking in almost
all the PHCs and also in some District Leprosy Offices.
8.2. MDT management
-
-
Indent of MDT for a district is computed by DLO and sent to CS office for
procurement of central depot. Based on the demand, the drug supply is
made by the depot to the CS office. However, there is a missing link
between PHC, DLO and CS office in the drug indent process.
Indents from the PHCs are directly made to the CS office and the same is
supplied.
At PHC, after confirmation and registration, first dose of MDT is started
and the rest of the doses are provided at the HSC by the ANMs
However, inspection of the stock revealed that inadequate stock of MB(A)
in all health facilities and MB(C) in some cases and excess of PB(A) in
some health facilities
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8.3. Simplified Information System
-
Registers are maintained and updated at the PHC
Collection and compilation of information as per the SIS guidelines is
satisfactory.
Monthly Progress Reports as per SIS format are prepared by the NLEP
staff and sent to the district and further to the State.
The reports are analysed, interpreted at the State level by the SLO/NLEP
Coordinator/DTST Coordinators
Since the HSC are involved in treatment of cases, Case cards are found
with the ANMs and the ANMs are involved in regularly updating of the
master register. However, some of the treatment completed cards were
found missing. Hence, action need to be taken that all the treatment card
to be returned to the PHC for proper record maintenance.
8.4. Monitoring and Supervision:
-
-
-
-
Monitoring and Supervision at the PHC and Health Sub-Centre levels are
carried out by the DTST’s – Contribution of the DLO/ District Nucleus is
inadequate
Interpretation of the indicators is not carried out PHC/ District levels.
Working out the indicators (PR/NCDR/MB prop/Child proportion) is being
carried out by the DTST’s and not by the NLEP staff at the PHC level
Though district nucleus has been formed and most of the identified
members have been trained the functioning of the nucleus leaves much to
be desired. In some districts at least the nucleus is made up of persons
situated in different units in different sites and as such they rarely come
together for planning their activities. In some places the supervisor posted
at the DLO office is not part of the District nucleus.
Mobility of the district nucleus is a serious problem. Most of the District
nuclei are reluctant to hire vehicles for various reasons. Therefore their
involvement in supervision and monitoring is very poor.
Supervision by the MO at PHC is inadequate. Rarely field visits are made.
This problem is not unique to leprosy.
While the clinical and operational competence of the supervisory staff is
good the managerial competence is inadequate. It is not clear how the
DTST will be able to improve this component of DN functioning.
8.5 . IEC activities:
- IEC is good in the district. The role of DLN and DTST is evident in the
form of display of posters, wall paintings in the PHC and important
strategic points
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-
8.6.
Management of reactions and POD :
-
-
8.7.
Innovative ideas are attempted in IEC.
This is one area where the role of DLN is obviously seen.
Interview with the patients also revealed adequate awareness about
the disease and the importance and duration of treatment.
Interaction with community members also revealed that there is
adequate awareness about leprosy and the availability of MDT at
PHCs free of cost. Interestingly, Women folks were better in
awareness level compared to the men folk.
ANMs can be involved and motivated to play a major role in IPC
Knowledge on POD and complications of leprosy cases especially on
reactions needs to be improved
ANMs and the Medical officers can be empowered with knowledge and
skills of self care to be advised to the patient.
Reconstructive surgery unit has been established at the Patna medical
College and been functioning since January 2004 with the technical
support from the DFIT. However, there is lack of follow up of cases after
surgery. It was found that the technical competence of the physiotherapist
needs to be improved and there is a need for second line of trained
physiotherapists for good results of the reconstructive surgery.
There is lack of referral system and linkage to be established so that
cases are referred from the PHC and later followed up properly.
Efforts of DTST in the integration process in the District and the
state level
-
-
-
Functioning of DTST is quiet evident in the state of Bihar in the
integration process and the results are obvious.
Capacity Building of the staff at all levels in diagnosis and
management of cases. Both on job training and the regular training are
done to enhance their knowledge and skills. DTST presence is felt and
their role is highly acknowledged by all the staff from the level of the
health sub centre to the state level.
However, there is a stronger need for capacity building in programme
management especially of monitoring and supervision.
On job training and regular training of both the Medical and
paramedical staff has helped in enhancing their confidence in case
management.
All the staff at the PHC and the district level are happy about their
technical support.
However there appears to be over dependence on them especially in
report preparation (calculating indicators) and sometimes in case
management
DTST Evaluation Report – Bihar (Final Version)
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-
8.8
Adequately managing the MDT supply.
Confirmation of doubtful cases and validation of registered cases on
counseling days.
Facilitating DLN in Organizing IEC programmes
Monitoring and supervision of the programme along with DLN.
However, the role of DLN is negligible and over dependent on DTST
Contribution of DTST at the District level
- DLN is in infancy stage and DTST is doing the major role of DLN.
They help them in preparing monthly reports.
- There is a need for empowering the DLN in programme
management –especially in activities such as drawing action plan,
planning field visits, monitoring and supervision skills etc.
- DTST take part in the district level meeting of District Health
Society as invited guests and DLO as member of the society. More
assistance can be sought.
- Coordination between DTST team, DLN and the Civil surgeon can
be improved
8.9
-
-
-
8.10
-
DTST management
Regular post of State level DTST coordinator is formerly the state leprosy
officer was in place. Sate level coordination between the DTST
coordinator, NLEP coordinator and the state officers is cordial.
Regular reports are sent to the sate DTST coordinator from different ILEP
agencies and in turn the State DTST coordinator sends to the state
officers
However it was found that there is a need for the state DTST coordinator
to visit other ILEP districts also.
Exchange of innovative ideas between the ILEP agencies was lacking and
the DTST state coordinator needs to liaison between the ILEP agencies
coordinators
NLEP present and future needs:
Sustain the integrated leprosy activities
Improve the quality of the leprosy services
Strengthen the District Nucleus and should be in place
Referral system for management of complications due to leprosy need to
be established at all the levels
The support of the DTST in areas of Monitoring and supervision / capacity
building among the middle level managers is needed
Information management as per SIS guidelines starting from the MO PHC
and above is required
DTST Evaluation Report – Bihar (Final Version)
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9. RECOMMENDATIONS
9.1
The integration at grass root level is highly satisfactory but at the level of
primary health centre, the capacity of the Medical officers in charge of these
centres needs to be further strengthened in the programme implementation
and management. This may be one area where DTST can support.
9.2 Integration at the secondary and tertiary level appeared to be incomplete.
The evaluation team felt continued support of DTST is desirable in order to
strengthen the integration at the secondary and tertiary level.
9.3 The contributions of DTST in the capacity building of gross root level staffs
like ANM have been well carried out. The ANMs are able to suspect leprosy
cases, refer them to the PHCs for confirmation, follow up cases for treatment,
update the master register, complete the entry of the treatment card and
ensure RFT. For better patient management, ANMs and the MOs can be
empowered with skills in self care.
9.4 At PHC level, confirmation of suspected cases is going on with the
participation of Medical Officers and the NLEP staffs. How ever, the sensory
testing skill needs to be improved by on-job training.
9.5 Monthly Reports are generated and submitted to the each district as per the
SIS guidelines but the importance of indicators is not realized at the PHC or
the district level and is not utilized for the programme management
9.6 Even though some shortage was observed in few categories of blister
packs, MDT drugs are supplied to the patients regularly. Hence, Regular
supply of Drugs need to be ensured.
9.7 Interaction with community also revealed adequate awareness about leprosy
and the availability of MDT at PHCs free of cost. However there is scope for
much more intense IEC activity more so to ensure voluntary reporting of
cases now.
9.8 . With these backgrounds, the utilization of the DTST in the present form is a
question.
9.9 Among Clinical component, Operational component and Managerial
component of the programme, the first two have been well achieved with the
involvement of DTST, in the districts visited by the team. Managerial
component, which is found lacking, needs to be undertaken by District
authorities. DTST in this regard cannot contribute much.
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9.10 The Monitoring, Evaluation and Supervision have to be strengthened
utilizing the manpower and resources, available at the district and PHC level.
9.11 Complications of reactions and POD care are not adequately managed at
the PHC and district level. With the declining prevalence of Leprosy, there is
need for effective referral system to be in place for management of POD and
rehabilitation to give special attention to the individuals already affected.
9.12 The District Leprosy Nucleus is constituted with the participation of
different officials at the district level. These members must be within the
same district so that they can interact with each other and plan their visit
programmes. The District nucleus is in the infancy stage and currently they
are defunct. District Leprosy Nucleus need to be strengthened and this may
probably be the one of the major focus area for DTSTs in future to
concentrate in enabling the DLN to become functional and be effective and
gradually become independent in the programme management. Since the
DLN is in transition of taking over the role of DTST, before the support of
DTST is withdrawn, there is a strong need for capacity building of the DLN
team to be in the streamline of the integration process.
9.13
Urban Leprosy Control needs a special focused attention.
9.14
Strengthen monitoring of DTST by the DTST coordinator
10. FUTURE STRATEGY TO BE FOLLOWED
10.1. Considering all these prevailing circumstances, it is recommended that the
present form of DTST placed at district level may be relocated and it can
operate at Zonal level.
10.2. Each DTST can take up 4 – 5 districts under their care. DTST can spend
four days in each district. Out of four days, one day they can spend in the
DLO office for management of complications and other related problems and
for the rest of 3 days they can visit 4 –5 problematic PHCs along with District
Leprosy Nucleus.
10.3. To carry out this, the team should plan the tour programme in consultation
with District Leprosy Nucleus. On the other days the District Leprosy
Nucleus can plan their visit to PHCs for counseling on their own utilizing the
budget allotted to them for that specific reason.
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11. ACKNOWLEDGEMENTS
The Evaluation team gratefully acknowledges the support extended by the
Director of Health Services, Government of Bihar, The State Leprosy
Officer, WHO coordinator and Other Officers and staff of Bihar
government in smooth conduct of the survey.
The Evaluators team gratefully acknowledges the kind hospitality provided
by the team of Damien foundation India trust which made our stay, travel
and evaluation a comfortable one.
Evaluation team also acknowledges the help rendered by civil surgeons;
DLOs and DLN teams; MO’s and Staff of BPHCs, APHCs, Sub-centres;
community members and patients.
Evaluation team’s thank are also due to the State coordinator, DTST
coordinators and all the staff (M.O., and the NMS) of the districts visited.
Last but not least, the evaluation team expresses its heartfelt thanks and
gratitude to ILEP member organisation for providing this opportunity of
evaluation to all the team members.
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