DISTRICT TECHNICAL SUPPORT TEAMS
PROJECT
2002 – 2004
STATE OF UTTAR PRADESH
INDIA
REPORT OF THE END EVALUATION
25 October 2004 – 4 November 2004
DISTRICT TECHNICAL SUPPORT TEAMS PROJECT
2002 – 2004
THE STATE OF UTTAR PRADESH
INDIA
REPORT OF THE END EVALUATION
25 October 2004 – 4 November 2004
-
Dr Andrews Deenabandhu, NLEP State Consultant, GLRA, Tamil Nadu, India
Dr K.V. Krishna Moorthy, Head Clinical Division, Blue Peter Research Centre,
LEPRA, Hyderabad, India
Dr V.P. Macaden, Retired Director, Hubli Hospital Handicapped, Hubli, Karnataka,
India
Dr R.N. Sabat, Chief Medical Officer (NFSG), RLTRI, Raipur, Chhattisgarh, India
Dr Jan Visschedijk, Public Health Specialist, The Netherlands (team leader)
ii
TABLE OF CONTENTS
TABLE OF CONTENTS ______________________________________________ iii
LIST OF ABBREVIATIONS __________________________________________ iv
EXECUTIVE SUMMARY______________________________________________ v
1.
INTRODUCTION ________________________________________________ 1
1.1 Background ____________________________________________________ 1
1.2 Purpose of the visit ______________________________________________ 1
1.3 Assessment methods _____________________________________________ 2
1.4 Evaluation team ________________________________________________ 3
1.5 Method of reporting _____________________________________________ 3
1.6 Programme of the visit ___________________________________________ 3
1.7 Acknowledgements ______________________________________________ 3
4.
FINDINGS, CONCLUSIONS AND RECOMMENDATIONS _____________ 8
4.1 Introduction ____________________________________________________ 8
4.2 Review of main objective _________________________________________ 8
4.3 Review of leprosy programme activities and contribution of district
technical support teams _____________________________________________ 9
4.4 Contribution of DTSTs to District Leprosy Societies _________________ 12
4.5 Other support of DTSTs to the leprosy programme _________________ 12
4.6 Functioning of DTSTs __________________________________________ 12
4.7 Functioning of the DTST-management ____________________________ 13
4.8 Responsibilities of first and second party ___________________________ 14
4.9 Review of recommendations of the MTE ___________________________ 14
5.
CONTINUATION OF THE PROJECT AND RECOMMENDATIONS ____ 15
APPENDIX I
– PROGRAMME OF THE VISIT ________________________ 17
APPENDIX II
- MAIN CONTACTS _________________________________ 18
APPENDIX III
– MAP OF UTTAR PRADESH_________________________ 20
APPENDIX IV
- TERMS OF REFERENCE ___________________________ 21
APPENDIX V
– RESPONSIBILITIES ACCORDING TO MOU __________ 23
APPENDIX VI
– REVIEW OF RECOMMENDATIONS MTE ____________ 25
APPENDIX VII
- DISTRIBUTION LIST ______________________________ 26
iii
LIST OF ABBREVIATIONS
AIFO
APHC
ANM
CMO
CHC
DDG(L)
DDP
DLO
DLS
DM
DTST
ESIS
GHS
GoI
GoUP
IEC
ILEP
LEC
MB
MDT
MLEC
MO
MoU
MTE
NGO
NLEP
NLR
NMA
NMS
PHC
PIP
PMA
PMS
PMW
PoD
SAPEL
SIS
S(H)C
SLO
SLS
TLM
ToR
UP
WHO
Amici di Raoul Follereau (Italian Leprosy Relief Association)
Additional Primary Health Centre
Auxiliary Nurse Midwife
Chief Medical Officer (District Medical Officer)
Community Health Centre
Deputy Director General (Leprosy)
Drug (MDT) Delivery Point
District Leprosy Officer
District Leprosy Society
District Magistrate
District Technical Support Team
Employees State Insurance System
General Health Service
Government of India
Government of Uttar Pradesh
Information Education and Communication
International Federation of Anti-Leprosy Associations
Leprosy Elimination Campaign
Multibacillary
Multi Drug Therapy
Modified Leprosy Elimination Campaign
Medical Officer
Memorandum of Understanding
Mid Term Evaluation
Non Governmental Organization
National Leprosy Eradication Program
Netherlands Leprosy Relief
Non-medical Assistant (often same as PMW)
Non-medical Supervisor
Primary Health Centre
Project Implementation Plan
Paramedical Assistant
Paramedical Supervisor
Paramedical Worker
Prevention of Disabilities
Special Action Plan for Elimination of Leprosy
Simplified Information System
Sub (Health) Centre
State Leprosy Officer
State Leprosy Society
The Leprosy Mission
Terms of Reference
Uttar Pradesh
World Health Organization
iv
EXECUTIVE SUMMARY
Background
In 1998 a project was established in Uttar Pradesh to strengthen the existing leprosy
programme through Zonal support teams. In 2002 these teams were renamed as District
Technical Support Teams and a Memorandum of Understanding was signed between the
Government of India (GoI), the Government of Uttar Pradesh (UP), The Leprosy Mission
(TLM), the Netherlands Leprosy Relief (NLR) and Amici di Raoul Follereau (AIFO). The
main objective was to facilitate integrating NLEP within the general health care services. The
District Technical Support Team Project started in January 2002 and lasts until December
2004. Though a Memorandum of Understanding existed, a more detailed working document
was not formulated for the project. An End Evaluation was foreseen in the MoU in the last
quarter of the project.
The End Evaluation was carried out by a team of five independent experts. Besides reviewing
relevant documents, visits were made to four districts, and discussions and meetings were
held with relevant staff at all levels. The evaluation was carried out between 25 October 2004
and 4 November 2004. The central topic was to assess the contribution of the project to
integration of leprosy control into the general health services. The major observations,
findings and recommendations were debriefed to the project-management, state health
authorities and representatives of the donors. They are also reflected in this report.
Major findings and observations
The End Evaluation found that important steps forward were made in effectively integrating
NLEP within the general health services. MDT drugs are available in most health facilities,
and the skills and knowledge of the general health staff concerning diagnosing and treating
leprosy patients improved. Also community awareness concerning leprosy increased greatly
over the past years. A simplified information system is operational. Importantly, the DTSTs
have substantially contributed to this success. They sensitised the staff at all levels in favour
of integration and enhanced their skills and knowledge through on-the-job training and
training courses. They ensured the supply of IEC materials and facilitated reporting and
recording, while at the same time supervising the drug provision.
Mostly the diagnostic skills of Medical Officers, who are generally diagnosing patients, are
fair, though about 10% of the cases are over-diagnosed. The percentage of under-diagnosis
remains obscure, though there are indications that in some areas still several patients remain
undetected. Most staff of the sub-centres know how to suspect and refer cases. Unfortunately,
they are not always involved in MDT-provision. Mostly case-holding is adequate, and
patients who become irregular are traced. Skills in prevention of disabilities and disability
care are limited. Particularly, the quality of leprosy services in urban areas remains
problematic, in case-finding as well as case-holding. In these settings, private and alternative
health providers have only limited knowledge of leprosy and defaulting is paramount.
In most health centres education materials are available. Continuous IEC activities have
resulted in reduced stigma in most communities. Nevertheless, communication skills of health
workers in delivering the core messages of leprosy to patients and the general public leave
room for improvement. Mostly training materials are available, though staff is not taught how
to make use of these materials.
The drug supply system in general functions fine, and no patients were found who did not
receive MDT in time. Some constraints exist in calculating the buffer stock and entries in the
drug register. The simplified information system is in place, mostly looked after by the former
vertical NLEP staff that have been absorbed into the general health care service. Problems
v
could be identified particularly in disability grading and consistency in entering patients in
registers in subsequent years. Unfortunately, most general health staff and district staff is
lacking skills in interpreting and analysing the data.
With a few exceptions, the District Leprosy Societies are still not working well, in spite of
efforts by the DTST-teams. These societies rarely meet, and conduct only a limited number of
activities.
The DTSTs were highly valued by general health staff and health authorities interviewed
during the evaluation, particularly because of their support in patient care, registration and
drug supply. Mostly they work in direct collaboration with the District Leprosy Officer
(DLO) and his team. Though DTSTs have to facilitate, some teams have a tendency to take
over activities. Prioritisation towards weak areas is rarely made. Analytic and problemsolving skills need some strengthening, and not all teams give sufficient feedback to the
visited health centres. Also planning skills are limited and the quality of the annual plan of
action needs to be improved and made more consistent.
Since the project co-ordinator started working in 2003, and the administrative co-ordinator
passed away, the last years were rather turbulent for the project-management. Currently, the
project-management focuses largely on the leprosy programme and to a lesser extent on the
DTSTs themselves. It also has a tendency to cover all DTSTs and all activities, while not
prioritising sufficiently. Also the rather new set-up, in which the co-ordinator has to
communicate with three supporting agencies requires some adjustments. However, the
collaboration in itself is a successful example of good co-ordination between different
agencies, and has strongly enhanced the uniformity of the DTSTs.
Major challenges
The End Evaluation has identified the following major challenges for the future:
 The integration process has not been fully completed. The level of integration varies
from place to place. Sub-centres are not always involved in MDT-provision, and the
skills and knowledge of leprosy in the PHCs is often not transferred to relevant health
staff, but still with the former vertical leprosy staff.
 Skills are not always adequate. Communication skills for health education by the
general health staff, planning, problem-solving and analytical skills of the DLO and
DTSTs need to be strengthened, as well as skills in PoD and disability care. Also the
management of drug supply at health facility and district level requires continuous
attention.
 Urban zones remain problematic areas in many aspects of leprosy control. This is due
to factors such as the complexity of the urban health system, migration, and culture.
In addition, several leading hospitals and urban health facilities are not following the
standard definitions for diagnosis, classification and treatment as mentioned in the
national guidelines developed by the NLEP.
 The capacity for leprosy control at the district nucleus (DLO and his team) requires
substantial strengthening, in order to sustain support to the leprosy activities.
 Though the Simplified Information System is in place and has made good progress,
certain aspects of recording and reporting still leave much room for improvement.
 District Leprosy Societies are not functioning adequately and not according to the
Project Implementation Programme.
 The activities of the DTSTs and the Project management are not prioritised, and
intend to cover everything too much. Also the project management focuses too much
on the whole leprosy programme, in stead of the functioning of the DTSTs.
vi


Feedback by the DTST and DLO to the PHCs has to be strengthened, as well as
feedback from the project management to the DTST teams and the supporting
agencies.
Since the DTST-project was formulated as a time-bound project, it requires a strategy
for sustainability.
Recommendations
1. The project should be continued for a period of 3 years, from 1 January 2005 until 31
December 2007. Also a working document (plan of action) should be formulated with
objectives, activities and targets.
2. DTSTs and the district nucleus should ensure that previous vertical staff share their
skills in leprosy control with general health staff and that, where possible, also subcentres become involved in the supply of MDT. This could be emphasized through
circulars from health authorities and during PHC- and district-meetings.
3. Since voluntary reporting is the main method of case-finding in the integrated leprosy
programme community awareness has to be enhanced. This can particularly be
achieved by sensitizing the Anganwadi workers and supervisors for leprosy control.
4. A stronger focus should be placed on urban areas.
5. The general health staff should be sensitised for disability care and rehabilitation.
They should be aware of the basics and, when necessary, refer to the relevant health
facilities.
6. Knowledge and skills on certain aspects of leprosy control should be strengthened,
i.e. interpersonal communication skills of general health staff, skills in management
of reactions and disability care of medical officers, and analytical and problemsolving skills of DTSTs and DLOs.
7. The state level should be sensitized in order to enhance the functioning of the leprosy
societies.
8. Case-validation by the DTSTs should be used to strengthen the capacity of the MOs
to diagnose leprosy.
9. A simple, consistent planning and budgeting system should be developed for the
DTSTs, in which priorities are made by the district.
10. The number of teams should roughly remain the same. The teams should at least
consist of a MO, a Paramedical Supervisor or Assistant and driver. In some areas,
such as urban, additional staff may be added to the team.
11. The activities of project management and of the DTSTs should be more prioritised,
and focused on areas and staff that require strengthening.
12. The project management should strengthen the monitoring of DTSTs, prioritise its
support to these teams, and produce quarterly reports on performance for the state
health authorities and the supporting agencies.
13. The supporting agencies should ensure one technical coach or backstopper for the
project management to discuss technical issues.
14. The project should in the coming period have a stronger focus on sustainability. This
implies that:
a. particularly the capacity of the district nucleus should be enhanced,
b. the DTSTs should emphasize their facilitating role,
c. the development of “withdrawal indicators” should be continued, and
d. the MTE should focus on sustainability and the consequences for the project
vii
1. INTRODUCTION
1.1 Background
When in 1998 a Memorandum of Understanding was signed between the Government of
India (GoI), the Government of Uttar Pradesh (GoUP), The Leprosy Mission (TLM) and the
Netherlands Leprosy Relief (NLR), the Zonal Teams Leprosy Project (ZLTP) took off. The
project supported the National Leprosy Eradication Programme (NLEP) through the
establishment of zonal teams. The aim was to strengthen leprosy activities within the existing
structure through support to Leprosy Control Units and the Primary Health Care system.
Sixteen zonal teams were created, later on expanded to 28. After the conclusion of the Zonal
Teams project of 3 years, these teams were redistributed over the districts and renamed as
District Technical Support Teams (DTST). When the Italian Leprosy Relief Association
(AIFO) became interested, they also took up support for some teams.
The Zonal Teams project was evaluated by the end of 2001. The evaluation concluded that
the project had significantly contributed to the performance of NLEP. It indicated that, since
integration of leprosy services into the general health services became the major strategy to
sustain leprosy services, the project should be continued. The evaluation suggested also a
change in the composition of the teams. The Physiotherapist was replaced by a Non Medical
Assistant, in addition to one Medical Officer (MO), one Non Medical Supervisor (NMS), and
a driver.
Subsequently a new Memorandum of Understanding (MoU) was formulated and signed by
representatives of the Government of Uttar Pradesh, The Leprosy Mission India Trust,
Netherlands Leprosy Relief – India Branch and Amici di Raoul Follereau. The main objective
of this new project was to facilitate integration of NLEP into the general health care services.
This was in line with the instruction of the Director General Health Services, UP that leprosy
should be diagnosed and treated by general health workers in every health facility. Former
vertical staff should support and supervise the general health staff.
The current District Technical Support Team Project started in January 2002 and lasts until
December 2004. It includes technical and logistical support through the DTSTs to the leprosy
programme by TLM, NLR and AIFO. Soon after the signing of the MoU the GoI requested
the project to cover only 49 high prevalence districts (prevalence of more than 4 per 10.000).
However, after the Mid Term Evaluation (MTE) in 2003 this was again expanded to cover all
districts. For 2004 an End Evaluation was foreseen.
1.2 Purpose of the visit
The terms of reference were formulated by the supporting NGOs in collaboration with the
GoI and GoUP. They were as follows:
1. To assess whether the activities performed by the DTST project comply with the
activities described in the MoU.
2. To check whether the findings and recommendations of the Mid Term Review of
September 2003 have been assimilated in the planning and execution of activities
since then.
3. To find out whether the activities mentioned under Responsibilities of First Party
(GoUP) and second Party (TLM/NLR/AIFO) have been carried out.
4. To assess whether in particular the activities of the Second Party have contributed to
the successful integration of leprosy services into the General Health Care system.
1
5. To identify discrepancies between planned and performed activities as per the MoU
and determine underlying reasons.
6. To determine whether the performed activities have contributed to the level of
General Health Care Services staff in terms of knowledge about case detection,
diagnosis, treatment, case-holding, identification and management of
complications/reactions, POD, health education, maintenance of records and registers
(correct implementation of SIS), compilation of data and generation of required
reports.
7. To assess the level of integration of leprosy services into the General Health Care
system and level of involvement of General Health Care Staff in leprosy control
activities.
8. To determine whether the training needs of NLEP and GHS staff have been identified
and addressed.
9. To determine whether assistance was given to District Leprosy Societies for
improving awareness and community participation.
10. To determine whether assistance was given to District Leprosy Societies in
monitoring and evaluation.
11. To assess the quality of co-operation and communication of the DTSTs with the
concerned district.
12. To assess the quality of co-operation and communication of the DTST State Project
Co-ordinator with concerned state and district authorities.
13. To assess the quality of co-operation and communication of the Project Co-ordinator
with DTSTs and assess whether Project Co-ordinator has contributed to the
strengthening of DTSTs functioning by supervisory visits.
14. To determine whether assistance was given to State Society in monitoring and
evaluation.
15. To assess whether any other assistance, technical or otherwise, has been given which
was not envisaged in the current MoU.
16. To make recommendations about the need and scope for continuation of the
collaboration described in the current MoU.
17. To make recommendations for the required number of DTSTs, organisational
structure of the DTSTs and their mode of functioning so as to provide effective
coverage.
18. To assess and recommend measures for effective collaboration of the project with
Central Leprosy Division of GoI, State government, District Leprosy Society,
General Health Care system and NLEP/Zonal Co-ordinators.
19. To assess the collaboration between ILEP partners supporting the DTSTs in the state
in relation to planning, monitoring the project and to recommend measures for
effective collaboration.
20. To produce the final Evaluation Report within 4 weeks after the completion of the
visits with inputs of comments and suggestions obtained by all main parties.
1.3 Assessment methods
The evaluation was conducted by utilizing different assessment methods:
-
-
Review of documents such as the Memorandum of Understanding (DTST 2002 –
2004), Report of the Mid Term Evaluation UP 2003, Report of the End Evaluation of
the Zonal Teams Leprosy Project UP 1998-2001, progress reports of the DTST and
other relevant documents.
Briefing sessions and discussions at state level with DTST Project Co-ordinator, State
Government authorities (State Leprosy Officer) and NLEP Coordinator UP.
Discussions with health authorities and health staff, including DTST-staff, involved
in leprosy control at all levels.
2
-
Analysis of patient records, registers and reports related to patients statistics and
activities of general health staff and the DTSTs.
Observations of activities and health structures during visits to health facilities.
1.4 Evaluation team
As was indicated in the MoU an independent End Evaluation was conducted before the
ending of the project, by a team consisting of independent experts (experts not directly
involved with the running and monitoring of the project) with one representative of GOI. The
evaluation team consisted of the following persons:
- Dr Andrews Deenabandhu, NLEP State Consultant, GLRA, Tamil Nadu, India
- Dr K.V. Krishna Moorthy, Head Clinical Division, Blue Peter Research Centre,
LEPRA, Hyderabad, India
- Dr V.P. Macaden, Retired Director, Hubli Hospital Handicapped, Hubli, Karnataka,
India
- Dr R.N. Sabat, Chief Medical Officer (NFSG), RLTRI, Raipur, Chhattisgarh, India
- Dr Jan Visschedijk, Public Health Specialist, The Netherlands (team leader)
1.5 Method of reporting
The major findings, conclusions and recommendations of the evaluation were discussed
during a briefing session in which the state health authorities, Project Co-ordinator and
representatives from NLR, TLMI and AIFO participated.
This report presents the findings and conclusions of the evaluation in more detail. Chapter 1
gives some general information about the project and the evaluation study. Chapter 2 briefly
provides some information on UP and leprosy control in UP. Patient statistics are presented
and discussed in chapter 3. In chapter 4 the findings, conclusions and recommendations of the
End Evaluation are presented. Chapter 5 discusses some future aspects of the project and the
need for continuation. In the appendices more detailed information concerning issues
discussed in the report can be found.
1.6 Programme of the visit
The evaluation was carried out between 25th October 2004 and the 4th November 2004. For
the field visits the team was divided into 2 teams. Team A (Dr Jan Visschedijk, Dr Andrew
Deenabandhu) visited the districts of Kanpur Urban and Rampur, while team B (Dr VP
Macadan, Dr KV Krishnamurthy, Dr Sabat) went to Ambedkar Nagar and Mirjapur. A
detailed programme can be found in Appendix 1. The main contacts are indicated in appendix
II.
1.7 Acknowledgements
The evaluation team is grateful for the hospitality and assistance received by all that were met
during the evaluation study, including the staff of the health facilities (CHCs, PHCs, SHCs)
and the DTSTs. Thanks are also going to the health authorities at district and state level.
Special acknowledgements should go to the DTST project co-ordinator, dr Bhandarkar, and
his
team
for
the
excellent
organisation
of
the
evaluation
study.
3
2. GENERAL INFORMATION
UP is still one of the most populated states in India. It is also one of the most endemic leprosy
states. Specific information on UP can be found in table 1. A map of the state, indicating the
districts is provided in appendix III.
Table 1 - Uttar Pradesh at a glance (www.upgov.nic.in)
Area
236,286 sq. km.
Population (2001 census)
166 million
Male: 87 million
Female: 79 million
Decennial growth rate
26%
Female literacy
70%
Districts
70
Towns
631
Recently the GoUP has started to integrate the leprosy programme into the general health
services. Hence, nowadays it is structured along the lines of the general health system and
administrative set-up. The State Leprosy Officer (SLO) is responsible for the overall
programme. WHO has seconded a State Co-ordinator to strengthen the state level capacity for
the leprosy programme.
After the recent separation of Uttaranchal in 2001 from the state, Uttar Pradesh consists of 70
districts. Though most districts have health facilities at district level, such as referral
hospitals, the health system is structured around Primary Health Centres (PHC). Some of
these have been upgraded to so-called Community Health Centres (CHC) and harbour
specialists. PHCs may serve areas up to 100.000 people. Mostly they are headed by a Medical
Officer (MO) in charge. They also function as referral centres for sub-centres and additional
Primary Health Centres. Sub-centres mostly have a catchment area of about 5.000 people.
Additional PHCs serve as a level in between.
Since the start of the 1st World Bank project, the so-called Project Implementation Plan (PIP),
for leprosy in 1994, District Leprosy Societies (DLS) have been established. These DLSs are
supposed to plan & monitor different leprosy activities, such as health education, in the
districts. They are chaired by the District Magistrate (DM). The chief medical officer (CMO)
of the district is the vice-chairman, while the DLO is the secretary. In 2001 also a State
Leprosy Society (SLS) was established to guide the programme and flow of funds.
4
3. PATIENT STATISTICS
Uttar Pradesh is not only the state with the highest number of inhabitants, it is also ranks
among the states with the highest prevalence and case detection in India. In this chapter some
statistical information concerning the leprosy problem in UP is presented and discussed. It
should be noted that before 2001 UP included the current state of Uttaranchal. Since the
population of this state is relatively small compared to UP it will not have influenced the
trends substantially.
Case detection and prevalence
The case detection and prevalence rate have fluctuated over the years (see figure 1 and figure
2) . This is particularly due to operational factors such active case finding through Modified
Leprosy Elimination Campaigns (MLECs). It is reflected in the high numbers of new cases
found in the years 1998, 1999 and 2001, when these exercises were carried out nation-wide.
When the numbers detected during these exercises are subtracted from the total numbers, the
case detection has fluctuated roughly between 60 to 90.000 new patients annually.
Figure 1 – New cases detected in UP
New cases detetected in UP (1991 -2003)
120000
100000
80000
60000
40000
20000
0
1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003
Figure 2 – Case Detection rate and Prevalence rate
CDR and PR in UP (1995-2003)
Rate per 10.000 pop
8
7
6
5
CDR
PR
4
3
2
1
0
1995 1996 1997 1998 1999 2000 2001 2002 2003
5
Though the prevalence rate is going down, a clear projection for future case detection is
difficult to indicate. Also field visits during the evaluation confirmed that still substantial
numbers of new patients were being found. For instance in Sarsaul Block in Kanpur about 10
patients per month were detected in 2004, similar to the number per month found in 2003.
Recent emphasis on validation and removal of recycled cases will certainly lower the
prevalence as well as the new case detection rate. Roughly about 10% of the cases are overdiagnosed. At the same it is also not clear how much under-diagnosis exists, making it
difficult to identify the real underlying epidemiological trends.
In September 2004 the registered prevalence rate stood at 2.8 per 10.000, while the national
prevalence rate was 2.4 per 10.000. Also the prevalence rate is influenced by operational
factors such as case-finding methods, cleaning of registers and reduction of duration of
treatment. A lower prevalence has surely reduced the workload at the health facilities. It can
be expected that the registered prevalence rate will be somewhat further reduced as a result of
cleaning of registers.
Patients with severe disabilities, children and MB patients among new patients
Figure 3 – Proportion of disability grade II and children
Percentage
Proportion of disability grade II and children in new
leprosy cases in UP (1995 - 2003)
16
14
12
10
8
6
4
2
0
% Gr II
% Children
1995 1996 1997 1998 1999 2000 2001 2002 2003
The proportion of disability grade II among new patients has been relatively low in UP, and
has during the past years even been further reduced. Also during the visits to the different
health facilities it was apparent that the registration of visible deformities was mostly nil. A
possible explanation could be that people report earlier to health facilities. However, also lack
of skills for adequate disability grading could be a contributing factor, particularly since the
classical signs of far evolved leprosy disabilities have become rather rare. During the
evaluation it was found that registration of disabilities was often inaccurate, making it
difficult to draw strong conclusions.
The percentage of children among new leprosy has fluctuated somewhat. This is most likely
to a large extent caused by active case-finding through MLECs and school surveys. Over the
last years it seems to be rather stable at about 8%.
The percentage of MB has increased in 1997 as result of changes in the classification. Since
1997 it has fluctuated between 40 and 45 percent, though there is substantial variation within
the districts and between districts.
6
Data from districts visited during the End Evaluation
In table 2 data are presented from the districts that were visited by the evaluation team.
Striking is the variability in the percentage of MB among new cases and the low percentage
of women among new patients. Also in terms of case detection, child rate and percentage of
disabilities some variability exists. It would require further research and analysis to identify
possible factors that influence these indicators.
Table 2 - Data of districts visited during the evaluation
(as of September 2004 – CDR based on period April – September 2004)
District
Case detection rate (per 10,000)
Prevalence rate (per 10,000)
Percentage MB
Percentage children
Percentage female
% patient with grade II disability
Ambedkar Nagar
3.2
3.0
57
4
25
2.0
7
Kanpur Urban
3.7
3.6
58
6
30
1.8
Mirzapur
4.2
3.5
30
8
32
0.8
Rampur
3.3
2.9
28
7
29
0
4.
FINDINGS, CONCLUSIONS AND RECOMMENDATIONS
4.1 Introduction
Though a MoU was signed by the parties involved, a working document, as was referred to in
this MoU, has not been formulated and signed. Also no specific targets in which the
objectives of the project were quantified, as proposed by the End Evaluation in 2001, were
incorporated. Hence, only the MoU and the Terms of Reference (ToR) could be used during
the evaluation. For the next phase it is recommended to formulate a working document in
which objectives, activities and targets for the DTST-project are indicated (see also
recommendation 1).
In order to respond to the terms of reference for the end evaluation, and to give an overview
of all relevant aspects of the DTST-project and the leprosy programme in UP, the relevant
findings and observations will be presented in the following format (see also appendix IV for
a response to the specific ToR):
- Review of main objective of the project
- Review of leprosy programme activities and contribution of the DTSTs
- Contribution of DTSTs to District Leprosy Societies.
- Other support of DTST to leprosy programme
- Functioning of DTSTs
- Functioning of DTST-management (including the collaboration of the project with its
partners, and between ILEP partners)
- Responsibilities of the first and second party
- Review of recommendations of the MTE
4.2 Review of main objective
Support to the integration process was formulated as the main objective of the DTST project.
Over the past years much progress has been made towards full integration of the leprosy
programme. This means that patients are diagnosed by the general health services and that
MDT is available in all Primary Health Centres (PHC) and Additional Primary Health Centres
(APHC). No vertical structures can be found anymore and previous vertical staff has been
mostly absorbed by the general health facilities, such as the PHCs. They have, however, not
transferred all knowledge and skills to general staff and they are often still doing certain
aspects of leprosy work, such as registration and defaulter tracing (see recommendation 2).
Mostly they also have other (general) duties.
Besides enhancing the accessibility of MDT services, integration has reduced the stigma of
leprosy. Leprosy patients now collect drugs from dispensaries in PHCs where also other
patients come for their drugs. In addition, the recently simplified information system (SIS) is
handled by the PHCs. No indications exist that the quality of services has suffered from
integration in terms of reduced diagnostic skills and lower treatment compliance. It has been
crucial that in this process much emphasis was placed on the capacity of the general health
staff.
The DTSTs have played a vital role in the integration process. In most settings they have
strengthened the knowledge and skills of the general health staff through training courses and
on-the-job training. Besides, they have sensitized and motivated health staff for integrated
leprosy control and ensured that the registration system and drug delivery system function
adequately. This supervisory role, which will remain an essential function of the district
nucleus (the district leprosy officer and his team), will ensure that the leprosy activities are
sustained.
8
Nevertheless, several sub-centres are still not delivering MDT to patients. Only a limited
number of committed ANMs have come forward to perform these important components of
leprosy control. Their involvement will increase the number of health facilities providing
MDT (see recommendation 2). Though sometimes it has been indicated that the ANMs in
sub-centres have already a substantial workload, MDT-provision will only give a very limited
extra burden. It can easily be combined with activities for other programmes or other leprosy
activities such as health education. Their involvement could be emphasized through special
circulars from the health authorities, and during PHC- and district-meetings.
Health education is required to enhance the level of awareness, particularly essential when
case-finding is predominantly depending on voluntary reporting. Health education can be
enhanced by for instance involving self-help groups, district health education bureau and the
educational department. Also other cadres such as Anganwadi workers and supervisors could
be sensitized. They work within the communities and can also be a useful source for
identification of suspected cases (see recommendation 3).
A clear target of the level of integration to be achieved in a given timeframe has not been
established. This would be helpful in determining the duration of DTST-support to the
districts. In Mirzapur for instance 6 years of support by DTSTs have achieved a moderate
level of integration. In Ambedkar Nagar the general staff is only comfortable with the
cardinal signs (patch and anaesthesia) of leprosy control after 15 months of support.
4.3 Review of leprosy programme activities and contribution of district technical
support teams
Case finding
Currently most patients are diagnosed through voluntary reporting to the health centres. Some
patients are directly going to the CHCs or PHCs, others have been referred by the staff of the
sub-centres. In several PHCs, the patient is diagnosed by MOs or, when available, by a
dermatologist. In others, it was found that former vertical staff is making the diagnosis and
classification, and only asks the medical officer to sign the patient card.
In urban areas patients are often first seen by private general practitioners, by non-allopathic
health workers or by so-called quacks (non-licensed). These health workers often lack
knowledge and skills for leprosy control. Hence, it is important that they are sensitised for
leprosy control and capable to suspect leprosy (see recommendation 4).
The validation exercises in which the patients were reassessed by experts, indicated that about
10% of the patients were over-diagnosed. The percentage of under-diagnosis remains
unknown. As far as could be observed during the evaluation, the diagnostic skills of most
MOs were fairly adequate. Some MOs, however, particularly those who recently were placed
at PHCs, lacked sufficient skills. Though a simple stream-diagram for diagnosis can be found
in almost all health facilities visited, several MOs were not aware of this diagram and did not
use it. It was mostly not explained to them how to use it.
Over the past years the DTSTs have also been actively involved in active case finding, e.g.
through rapid surveys in villages, healthy contact surveys and school surveys. Recently,
however, the GoI has discouraged active finding, indicating that case-finding should be based
on voluntary reporting. DTSTs have also facilitated several IEC activities which have
enhanced the awareness of leprosy in the communities and reduced the stigma of leprosy.
9
This is crucial to ensure that patient are reporting themselves when they have suspect skin
lesions.
Case holding
Most patients return to the PHCs when they have to continue MDT-treatment. Side effects are
rarely seen. In some PHCs the pharmacist is providing new blister packs, in others the former
vertical staff does. If patients report any problem, they are mostly presented to the MO. When
patients are irregular they are traced, mostly by the former vertical staff. The sub-centres are
not always involved in the provision of MDT. In most areas almost 90% of the patients
complete their treatment. In urban areas, however, defaulting is substantial. Most clinicians,
who are experts in diagnosing, regard follow-up as a responsibility for the leprosy
programme. During visits to these health facilities it was found that case-holding was
problematic and many patients default for various reasons (migration, urban culture). Default
tracing was carried out by DLO-staff, but not always successful.
Accompanied MDT was provided in several health facilities, but most health workers
indicated that it should be an exception. Hence, rarely MDT was distributed in large amounts
to patients.
During their visits, DTSTs assess patient-cards and the register, and emphasize the
importance of compliance. They advise on action to be taken when patients are irregular.
Particularly, in urban areas the importance of compliance has to be emphasized through
patient education.
Prevention of Disabilities and disability care
Prevention of disabilities (PoD) is regarded as an integral part of leprosy control. This
particularly implies that reactions should be detected and treated in time. During the
evaluation it was found that the number of reactions detected was relatively low. No
systematic recording, however, exists and the reports from MOs differ substantially.
Dermatologists seem to detect more reactions. In order to determine whether this is due to a
real low number of reactions, to lack of skills, or to self-referral of patients to more
specialised facilities would require further study. Obvious was, however, that the knowledge
and skills of many MOs to diagnose and treat patients for complications is rather limited.
Treatment is mostly according to the guidelines, though some MOs base the dose on the
clinical picture. Prednisolon is available in most facilities, sometimes as loose drugs,
sometimes as Prednipacs.
Also disabilities are rarely detected. The recording of the disability grade on the patient card
and in the register is often inaccurate. The knowledge of care for patients with disabilities,
visible and non-visible, is mostly limited. Health staff is rarely familiar with possibilities to
refer patients for further treatment or preventive devices, such as footwear and spectacles.
Clearly, these are areas which need to be strengthened in the coming years (see
recommendation 5).
Only a few DTSTs have emphasized the need of care for disabled patients. These activities
are mostly limited to advice to MOs. In those circumstances, they should be able to assist in
identifying and referring patients for disability care to other institutions, e.g. Non
Governmental Organisations (NGO) and hospitals.
Health Education
When patients are detected they mostly receive health education of the PHC-staff. However,
the quality of health education varies substantially. As could be observed during the end
10
evaluation, many health workers lack adequate communication skills to deliver the most
important messages. Sometimes health education materials are missing.
Several, but not all, PHCs have been involved in health education exercises. Posters can
nowadays be found in all PHCs and health education material is available in many health
facilities. Health education has been conducted through different media over the past years,
often with the assistance of the DTST. Such efforts should be enhanced, since voluntary
reporting can only be adequate if some awareness about leprosy exists in the communities.
Cadres that work within the communities, such as the Anganwadi workers should be involved
(see also chapter 4.2).
Training
Training has been taken up particularly around the period of MLECs. But also the DTSTs
have contributed substantially to the capacity building in leprosy control. This has been
achieved through training courses, as well as through on-the-job training. Meetings with
district staff and PHC-staff, were often used to strengthen the knowledge of health workers.
The evaluation revealed that the majority of health staff has been trained in different aspects
of leprosy control. However, since the turn-over of staff is high, this has to be continued in
the coming years. Such training should focus on the tasks and responsibilities of the specific
health worker in leprosy control.
Though training has been organised for Medical Officers, the main beneficiaries have been
the Medical Officers in charge of health facilities. Several other doctors have not had the
opportunity to undergo training in important aspects of leprosy control such as management
of reactions and disability care. In future DTSTs should ensure that all doctors of a health
facility are involved these training sessions.
Training materials are available at PHCs but to what extent they are utilized to disseminate
knowledge and skills to peripheral staff is not clear. It is important for adequate utilization
that these materials are discussed with the general health staff.
During the evaluation several areas could be identified that need to be strengthened through
training in the coming years (see also recommendation 6):
 Training of General Practitioners in leprosy, particularly in urban areas. Also
traditional doctors (homeopaths and ayurvedics) need to be trained to suspect and
refer.
 Training of MOs in diagnosis and treatment of reactions, and in disability care
 Training of health staff in counselling and health education
 Training of DTSTs and DLOs in problem solving and analytical skills
Supervision
Supervision of the facilities has to be conducted by the district nucleus, i.e. the DLO and his
team. However, due to several factors, such as other duties, lack of transport or vacant
positions, this has not always been possible. Sometimes the DTSTs have been a substitute for
the DLOs in supervision. Mostly the DTSTs operate in direct collaboration with the DLOs,
and plan their visits to the health centres in line with supervisory plan of the DLO.
Recording and Reporting
The simplified information system (SIS), which has recently been introduced, is operational
in all districts. In general, the cards, registers and forms are filled in according to the
guidelines, mostly by the previous vertical staff. Some aspects, such as the disability grading,
11
need extra attention. Also doubt exist in several PHCs concerning the registration of patients
that need to continue their treatment into the next year. In some PHCs discrepancies between
data on patient cards and treatment register were found.
The monthly reports are mostly adequately completed by the PHC-staff. The DLOs compile
these reports. However, within the district and at district level the skills to interpret and
analyse data in order to identify problems is rather limited and needs strengthening.
Logistics and drugs supply
Over the past years the programme has been able to provide MDT-drugs to all patients in
time. However, during the evaluation some inaccuracies in drug management were found.
The buffer stock was not always adequate and some wrong entries were made in the drugregisters. The DTSTs have facilitated the supply of drugs substantially, through checking the
registers and giving on-the-job training in drug-management.
4.4 Contribution of DTSTs to District Leprosy Societies
The District Leprosy Societies (DLS) are meant to monitor and manage the programme,
Funds are available from the Project Implementation Project (World Bank). Most of the
DLSs, however, are not functioning adequately. The members rarely meet and the number of
activities is rather restricted. Though the District Magistrate is the chairman of the society he
is not always aware of his role. Also not all CMOs, who are the vice-chairmen, seem to be
motivated. Though some DTSTs have tried, together with the DLO, to regularize the
society’s meetings, this has not been very successful.
At state level the State Leprosy Society has been established. The DTST project co-ordinator
is a member of this society. In meetings financial issues are discussed in relation to the plan
of action, which is a compilation of the district plans. State level authorities could be
sensitized to use their position to enhance the functioning of the DLSs (see also
recommendation 7).
4.5 Other support of DTSTs to the leprosy programme
When the MoU was signed it was not foreseen that so much emphasis in the activities of the
DTSTs would be placed on validation of cases. Validation exercises indicated that about 710% of the cases were wrongly diagnosed. Also several old cases were found that were
recorded as new cases. Though it is important to have only genuine leprosy cases been treated
with MDT and recorded as new cases, the main task for DTSTs in this context will be to train
the general health staff in such a way that they themselves can diagnose leprosy properly.
Hence, validation should always be part of on the job training (see recommendation 8).
Other activities that were not clearly spelled out in the MoU, are the involvement of the teams
in skin and PoD camps. Furthermore, DTSTs themselves have provided registers (e.g. for
drugs) in health centres, and translated and provided formats and reports in Hindi.
4.6 Functioning of DTSTs
The activities of the DTSTs were highly appreciated, both by the district authorities as well as
by the peripheral health staff. They particularly value the support through on-the-job training.
The teams have been very beneficial in areas such as IEC, checking of records, monitoring of
12
drug supply, and assistance in diagnosing and treatment of reactions. Sometimes, even some
dependence of technical knowledge may have been created. Some DTST staff have also a
tendency to take over responsibilities which are with the district nucleus. In general, the
technical competence of the DTST team members is adequate, though the managerial skills,
e.g. problem-solving and analytical, require strengthening.
Mostly it is possible for the DTSTs to visit health centres regularly, often in collaboration
with DLO. During these visits the interactions are with the MO i.c., the former vertical staff
and the pharmacist. Efforts are made to participate as much as possible in the monthly
meetings of the PHCs. The visits are planned in advance, and transport is mostly adequate. In
districts where there is no DLO, or where the activities of the DLO are limited or the district
nucleus is rather weak, DTSTs often fill in this gap. Important, however, remains that the
teams are not taking over the job of the district nucleus, but instead strengthen its capacity.
Three-monthly meetings are organized, in which all DTSTs participate. State authorities and
representatives of the supporting ILEP-partners also contribute to these meetings. The annual
planning of the DTSTs, however, is rather weak. The district plans are not consistent, do not
have a clear format, and the concepts of objectives, indicators, etc. are not always understood.
Also priorities can not sufficiently be set in the district, since much of final decisions
concerning approval of the activities are made by the project-management (see
recommendation 9).
The current composition of the DTST is fine, though in areas were more support is required
additional staff could be added to the team. The recent reduction of the team by making one
PMS or PMA redundant has had no negative impact on its performance. Hence, also in the
coming years the teams should consist of one MO, one PMS/PMA and a driver. However,
some flexibility should be taken in account, for in stance in areas where extra support is need
(urban areas). Here, extra staff could be added to the teams (see recommendation 9).
Feedback to the PHCs is not always sufficient and could be enhanced, for instance, by entries
into diaries to help monitor and evaluate the work. The DTSTs should also be more focused
on analysing data and identifying problems.
Currently, the number of DTSTs is adequate. However, most DTSTs try to cover as much as
possible areas and PHCs. They do not prioritise sufficiently on districts, PHCs, and areas that
need extra attention. Prioritization would definitely enhance their impact on the leprosy
programme (see recommendation 10). DTSTs may also shift their offices to districts where
more support is required.
4.7 Functioning of the DTST-management
The past years have been rather turbulent for the project management. It took a long time
before a project co-ordinator could be found, while the administrative co-ordinator recently
passed away. Furthermore, the project set-up in which three NGOs finance and support the
DTSTs in a state through one single project was rather new. Nevertheless the project
management has made good progress, particularly in collaborating with the state authorities.
Monthly meetings are taking place, in which activities are formulated and reviewed, and
information about visits is exchanged to prevent overlap. The management has also been
involved in identification of SAPEL & LEC areas and IEC workshops at state level. A
syllabus was prepared indicating the training needs of medical officers and supervisors. The
management also provided refresher training for DTST-MOs and PMSs.
During the evaluation certain areas could be identified that will require extra attention in the
next period:
13
-
-
-
The focus of the project management should be more directed to the project, i.e. the
functioning of the DTSTs, rather than on the whole leprosy programme. Programme
management particularly is the responsibility of the SLO and his team.
Support to the DTSTs will require regular feedback on their performance and reports.
The high number of teams makes it necessary for the project-management to focus on
those DTST that are relatively weak or require extra support (see recommendation
11).
It remains important to continue the collaboration with the SLO and his team. New
initiatives, e.g. should be discussed in the monthly meetings with the state authorities.
An adequate reporting system to the NGO-partners is not yet in place, and some
ambiguity exists about the technical support from the partners to the project
management. This can be improved through quarterly reports, in which particularly
the performance of the DTSTs is analysed, and by ensuring one technical
backstopper/coach for the project management (see recommendations 12 and 13).
The project set-up in which three different ILEP-partners support one project is an excellent
example of donor-co-ordination. This has particularly been possible because the GoUP has
appreciated the advantages of such a model. Important is the uniformity of the project, both in
approach as well as in operational terms such as the composition of teams and conditions of
work. Clearly, this co-operation should continue, and may be expanded to other states.
4.8 Responsibilities of first and second party
Though no working document was formulated, the MoU spelled out clear responsibilities for
both the first party (Government of Uttar Pradesh) and the second party (TLM-India, NLRIndia Branch and AIFO). The responsibilities of the second Party particularly related to
formation and functioning of the DTST-project and were broadly phrased. In general, it can
be concluded that both the first and second party have adhered to their responsibilities (see
appendix V).
4.9 Review of recommendations of the MTE
Though not all, the most relevant recommendations have been implemented. The technical
capacity has been increased through training, the DTSTs have been expanded to cover all
districts, monthly meetings are held, and the DTST-office is mostly located in a DLO-office
in one of the districts covered by the team (see also appendix VI).
14
5.
CONTINUATION OF THE PROJECT AND RECOMMENDATIONS
It can be concluded that overall the project has significantly contributed to the successful
process of integrating leprosy control into the general health services. However, the process
has not been completed. There are still areas and issues that have to be tackled, such as
leprosy control in urban areas, better involvement of the lower levels of the health system and
the private facilities. Furthermore, the achievements that have been made, need to be
maintained by continuing training of new MOs and other staff that recently have been posted
in the health centres.
Also for the future, it remains crucial that the general health system has sufficient staff for
supervision, training and monitoring, to ensure that leprosy control continues, even when the
registered prevalence has been further reduced. This requires that particularly the capacity of
the district nucleus and general health staff is sufficiently enhanced. Hence, the DTST project
should be continued for 3 years, along the lines formulated in the recommendations. To guide
this phase a working document should be formulated (see recommendation 1).
Since the project is meant to be time-bound and its impact to be made sustainable, it should
focus more on sustainability in the coming years. This implies that more efforts have to be
made to strengthen the district nucleus, while the facilitating role of DTSTs should be
emphasized. Furthermore the development of “withdrawal indicators” should be continued
and a MTR should be organized mid 2006 with sustainability as a central theme (see
recommendation 14).
Recommendations
1. The project should be continued for a period of 3 years, from 1 January 2005 until 31
December 2007. Also a working document (plan of action) should be formulated with
objectives, activities and targets.
2. DTSTs and the district nucleus should ensure that previous vertical staff share their
skills in leprosy control with general health staff and that, where possible, sub-centres
become involved in the supply of MDT. This could be emphasized through circulars
from health authorities and during PHC- and district-meetings.
3. Since voluntary reporting is the main method of case-finding in the integrated leprosy
programme community awareness has to be enhanced. This can particularly be
achieved by sensitizing the Anganwadi workers and supervisors for leprosy control.
4. A stronger focus should be placed on urban areas.
5. The general health staff should be sensitised for disability care and rehabilitation.
They should be aware of the basics and, when necessary, refer to the relevant health
facilities.
6. Knowledge and skills on certain aspects of leprosy control should be strengthened,
i.e. interpersonal communication skills of general health staff, skills in management
of reactions and disability care of medical officers, and analytical and problemsolving skills of DTSTs and DLOs.
7. The state level should be sensitized in order to enhance the functioning of the leprosy
societies.
8. Case-validation by the DTSTs should be used to strengthen the capacity of the MOs
to diagnose leprosy.
9. A simple, consistent planning and budgeting system should be developed for the
DTSTs, in which priorities are made by the district.
15
10. The number of teams should roughly remain the same. The teams should at least
consist of a MO, a Paramedical Supervisor or Assistant and driver. In some areas,
such as urban, additional staff may be added to the team.
11. The activities of project management and of the DTSTs should be more prioritised,
and focused on areas and staff that require strengthening.
12. The project management should strengthen the monitoring of DTSTs, prioritise its
support to these teams, and produce quarterly reports on performance for the state
health authorities and the supporting agencies.
13. The supporting agencies should ensure one technical coach or backstopper for the
project management to discuss technical issues.
14. The project should in the coming period have a stronger focus on sustainability. This
implies that:
a. particularly the capacity of the district nucleus should be enhanced,
b. the DTSTs should emphasize their facilitating role,
c. the development of “withdrawal indicators” should be continued, and
d. the MTE should focus on sustainability and the consequences for the project
16
APPENDIX I – PROGRAMME OF THE VISIT
25 October 2004
26 October 2004
27 October 2004
28 October 2004
29 October 2004
30 October 2004
31 October 2004
1 November 2004
2 November 2004
3 November 2004
4 November 2004
5 November 2004
Arrival of evaluators in Lucknow
Debriefing by NLR representative, meeting with evaluators,
meeting with SLO and WHO Consultant and Project Director.
Team A travels to Kanpur Urban.
Team B travels to Ambedkar Nagar.
Team A: Meeting with DTST, CMO, DLO Kanpur Urban,
meeting with CMO and deputy commissioner Municipal
Corporation, Kanpur Urban. Visit to Sarsaul CHC, Maharajpur
ANM Centre and Hathipur APHC.
Team B: Meeting with DTST team. Visit to Akbarpur District
Hospital, visit to Bhiti PHC.
Team A: Visit to ESI hospital Kidwai Nagar, visit to B.N. Bhalla
Corporation Hospital, visit to Ursula Horseman Memorial
Hospital. Meeting with DTST and DLO.
Team B: Visit to Jihangirganj PHC, Jalalpur PHC. Meeting with
CMO.
Team A: Visit to Sheorajpur PHC. Travel to Rampur.
Team B: Visit to Jamunipur APHC. Meeting with Ayurverdic
MO. Travel to Mirzapur.
Team A: Meeting with CMO Rampur, visit to Bilaspur PHC, to
Manpur Ojha APHC and to Chamrhawa PHC.
Team B: Visit to Gurusandi Block PHC, visit to Padari PHC.
Meeting with DLO and CMO.
Report writing
Team A: Visit to Shahabad CHC, visit to Rampura APHC, visit to
Bandar SC, visit to Himmalpur SC. Meeting with DLO and DTST
Rampur.
Team B: Visit to Mirzapur District Hospital, visit to Kachua PHC
and visit to Shikar PHC. Observation of IEC activities in
community.
Team A: Travel to Lucknow. Discussion with Project Leader.
Team B: Visit to Chilh PHC, meeting with District Magistrate,
Mirzapur, and visit to ESIS hospital Mirzapur. Travel to Lucknow.
Meeting evaluators. Meeting with state health authorities.
Discussion with NGO-representatives. Preparation for debriefing.
Debriefing and discussion of evaluation.
Report writing. Debriefing of Principal Secretary Medical Health.
Departure of evaluators.
17
APPENDIX II
- MAIN CONTACTS
Lucknow
Mr Siddhartha Behura
Dr. M.A. Arif
Dr. Rajan Babu
Mr. M.V. Jose
Dr. Mani Mozhi
Dr. B.K. Mishra
Dr. Leena Johri
Dr. Rashmi Tiwari
Dr. A. Siddiqui
Dr. K.L. Bhandarkar
Mr. Vishwas Manmode
Principal Secretary Medical Health
NLR Country Representative
Head of Evaluation Cell TLMI India Office
Administrator, Amici di Raoul Follereau, India
Medical Advisor, Amici di Raoul Follereau, India
State Leprosy Officer, UP
State Project Director, UP
NLEP Consultant UP (funded by WHO)
Zonal Medical Officer Leprosy, UP
Project Co-ordinator, DTST Leprosy Project, UP
Business Manager, DTST Leprosy Project, UP
Kanpur
Dr. H.C. Pandey
Dr. Ramesh Babu
Dr. Smita Asthana
Mr. J P Samuel
Dr. Suman Mistra
Mr. D.K. Panduj
Dr. R.S. Diwakar
Dr. Ashok Kumar
Dr. AK Singhal
Dr. Ashok Kumar
Dr. JMS Gabrial
Dr. VK Goyal
Dr. R Joeshpes
Dr. SC Mishra
Dr. GS Dhanik
Dr. RC Saini
Dr. Arvind-Yadav
MO, DTST, Lucknow (ex DTST Kanpur)
DLO Kanpur
MO, DTST Kanpur
NMA, DTST Kanpur
CMO Nagar Migam (Corporation), Kanpur Nagar
Deputy Commissioner (Corporation), Kanpur Nagar
CMO, Kanpur District
MO i.c., Sarsaul CHC
Dermatologist, Sarsaul CHC
MO i.c. Hathipur APHC
MO i.c., ESI Kidwai Nagar
Physician, ESI Kidwai Nagar
MO i.c., BN Bhalla Corporation Hospital
MO, BN Bhalla Corporation Hospital
Dermatologist, Ursala Horseman Memorial Hospital
MO i.c., Sheorajpur
MO, Sheorajpur
Rampur
Dr. Akhileswar Singh
Mr. Niranjan Singh
Dr. A.U. Khan
Dr. N.B. Sharma
Dr. Azfar Kamal
Dr. Ashok Rastogi
Dr. Ritu Rastogi
Mr. S C Gupta
Dr. R. Agarwal
Dr. S. Husain
Mr. R. P. Patel
Ms. Shyamla
Ms. Tulsi
MO, DTST, Rampur
NMA, DTST, Rampur
CMO, Rampur
DLO, Rampur
MO i.c., Bilaspur PHC
MO, Bilaspur PHC
MO, Manpur Ojha APHC
Pharmacist, Manpur Ojha APHC
MO i.c., Chamrahwa PHC
MO, Chamrahwa PHC
Pharmacist, Shahabad CHC
ANM Bandar SC
ANM Himmalpur SC
18
Ambedkar Nagar
Dr. Rajendra Prasad
Mr. Ramjanam Rai
Dr. Ramshankar
Dr. Ramdhirendria
Dr. Pradeep Kumar
Dr. R.K. Dash
Dr. Shobha Ram
Mr. B.C. Chaturvedi
Dr. RP Mourya
Dr. Dileep Kumar Giri
Mr. PC Yadar
Ms. Saraswati
Mr. Dmesh Kumar
Ms. Campa Deri
Mr. Satish Chandra
Mr. R.P. Mishra
Ms. Charapaderi
CMO, Ambedkar Nagar
Physiotherapist, Ambedkar Nagar
MO i.c., District Hospital
MO, District Hospital
MO, District Hospital
MO, District Hospital
MO i.c., Bhiti PHC
Pharmacist, Bhiti PHC
MO i.c., Jamunipur PHC
MO, DTST
NMA, DTST
ANM, Jamunipur PHC
NMA, Jihargirganj
Health Visitor, Jihangirganj PHC
Pharmacist, Jihargirganj PHC
NMS, Bhiti PHC
Health Visitor, Jihargirganj PHC
Mirzapur
Mr. Shobraj Singh
Dr. R.V. Singh
Dr. B. Panday
Dr. Dwivedi
Mr. K.P. Yadan
Dr. Madanlal
Ms. Janaki Devi
Ms. Mary Kuthy
Dr. R.R. Ram
Ms. Malathi Singh
Dr. R.R. Rai
Dr. V.K. Verma
Dr. J.P. Vishwakarma
Dr. V.B. Singh
Mr. Chandra Pandi
Ms. Susheeladari
Ms. Maniraj Deri
Ms. Kusim Singh
Dr Paltah
District Magistrate
DLO, Mirzapur
MO, DTST
Dermatologist, District Hospital
NMS, District Hospital
M.O. Gurusandi PHC
ANM Gurusandi PHC
ANM Gurusandi PHC
MO i.c. Padari PHC
ANM, Padari PHC
MO Kachua CHC
MO Kachua CHC
MO i.c. Shikar PHC
MO Shikar PHC
NMA, Shikar PHC
ANM, Chilh, PHC
Lady Health Visitor, Chilh PHC
Lady Health Visitor, Chilh PHC
MO, ESI Hospital, Mirzapur
19
APPENDIX III
– MAP OF UTTAR PRADESH
20
APPENDIX IV - TERMS OF REFERENCE
Description
Findings
To assess whether the activities performed by the The MoU describes only a limited number of
DTST project comply with the activities described activities of the DTST project and the DTSTs in
in the MoU.
very general terms. Nevertheless, it can be
concluded that the activities of DTSTs have
complied with these activities.
To
check
whether
the
findings
and Though
not
all,
the
most
relevant
recommendations of the Mid Term Review of recommendations (1, 3, 5 and 8) have been
September 2003 have been assimilated in the implemented. See also appendix VI.
planning and execution of activities since then.
To find out whether the activities mentioned The MoU describes the responsibilities of all
under Responsibilities of First Party (GoUP) and parties, to a lesser extent the specific activities. In
Second Party (TLM/NLR/AIFO) have been general, it can be concluded that the parties have
carried out.
taken up their responsibilities as described in the
MoU. More specific information can be found in
appendix V.
To assess whether in particular the activities of the Activities of Second Party are carried out through
Second Party have contributed to the successful the DTSTs. These activities have significantly
integration of leprosy services into the General contributed to the successful integration (see also
Health Care system.
chapter 4.2).
To identify discrepancies between planned and As is indicated above, both parties took up their
performed activities as per
the MoU and responsibilities and executed most relevant
determine underlying reasons.
activities as was indicated in the MoU (see also
appendix V).
To determine whether the performed activities The activities of the DTSTs together with the
have contributed to the level of General Health activities of the GoUP have substantially
Care Services staff in terms of knowledge about contributed to the quality of leprosy services.
case detection, diagnosis, treatment, case-holding, Nevertheless some weaknesses were found, e.g. in
identification
and
management
of identification/treatment of reactions, disability
complications/reactions, PoD, health education, care and analysis of records. Also some areas,
maintenance of records and registers (correct such as urban, still face serious constraints in caseimplementation of SIS), compilation of data and holding.
generation of required reports.
To assess the level of integration of leprosy The level of integration of leprosy services has
services into the General Health Care system and been enhanced substantially over the past years
level of involvement of General Care Staff in (see chapter 4.2).
leprosy control activities.
To determine whether the training needs of NLEP The training needs have been identified. However,
and GHC staff have been identified and addressed. this is a continuous process and also currently
there are cadres and areas that require training (see
chapter 4.3).
To determine whether assistance was given to Assistance was given to DLS, which has
District Leprosy Societies for improving facilitated IEC activities to some extent. However,
awareness and community participation.
in most districts the DLS is not functioning
adequately.
To determine whether assistance was given to Such assistance was not given. However,
District Leprosy Societies in monitoring and monitoring and evaluation is not a responsibility
evaluation.
or activity of the DLS. Hence, such assistance is
also not required.
To assess the quality of co-operation and The quality of co-operation between DTSTs and
communication of the DTSTs with the concerned DLO/CMO has usually been good, and was highly
district.
valued by the district health authorities. They
indicated that regular and relevant communication
took place with the DTSTs.
21
Description
Findings
To assess the quality of co-operation and
communication of the DTST State Project Coordinator with concerned state and district
authorities.
The quality of co-operation with the state
authorities is adequate and appreciated by all
parties. Monthly meetings are held, in which
mutual plans and observation are discussed and
fine-tuned.
The communication of the project co-ordinator
with the DTSTs needs to be strengthened. The
focus of the project management should
particularly be on those areas and DTSTs where
extra attention is required. Supervisory visits to
these DTSTs should be enhanced.
Assistance is given for activities such as surveys
and health education activities, not for monitoring
and evaluation. However, survey and health
education is also not a responsibility of the State
Leprosy Society.
Much assistance was given to validation of cases
by the DTSTs. Though it is important that overdiagnosis is minimised, the core task of the DTSTs
should be to train general health staff in adequate
diagnosis.
It is advised to continue the collaboration for the
coming three years, according to the remarks
made in chapter 5 and the recommendations.
The number of DTSTs should remain the same.
The DTSTs are able to give relevant support to 2-3
districts, while not taking over the role of the DLO
(see also chapter 4.6).
In general the collaboration of the project with the
relevant stakeholders is fair (see chapter 4.6 and
4.7).
To assess the quality of co-operation and
communication of the Project Co-ordinator with
DTSTs and assess whether the Project Coordinator has contributed to the strengthening of
DTSTs functioning by supervisory visits.
To determine whether assistance was given to
State Society in monitoring and evaluation.
To assess whether any other assistance, technical
or otherwise, has been given which was not
envisaged in the current MoU.
To make recommendations about the need and
scope for continuation of the collaboration
described in the current MoU.
To make recommendations for the required
number of DTSTs, organisational structure of the
DTSTs and their mode of functioning so as to
provide effective coverage.
To assess and recommend measures for effective
collaboration of the project with Central Leprosy
Division of GoI, State government, District
Leprosy Society, General Health Care system and
NLEP/Zonal Co-ordinators).
To assess the collaboration between ILEP partners
supporting the DTSTs in the state in relation to
planning, monitoring the project and to
recommend measures for effective collaboration.
In general the collaboration between the partners
is good. However, it is important that the projectmanagement gets sufficient coaching and is able to
discuss technical matters with the partners (see
chapter 4.7 and recommendations).
To produce the final Evaluation Report within 4 All main parties have been given the opportunity
weeks after the completion of the visits with to make their inputs.
inputs of comments and suggestions obtained by
all main parties.
22
APPENDIX V
a.
– RESPONSIBILITIES ACCORDING TO MOU
Main responsibilities of the first party, as formulated in MoU
Description
Findings
The government of UP shall give a formal letter of
approval for continuation of DTST for the state for the
stated period.
The First Party shall inform all concerned DLSs
regarding involvement and role of DTST and issue
instructions to DLSs to utilise the assistance of the
DTST.
The First Party shall issue appropriate instructions to all
district CMOs regarding the involvement of GHC in
leprosy elimination activities.
The First Party shall continue to take all necessary steps
to carry out NLEP activities, implementation of
integration with General Health Care services which
involves:
a. To carry out a district-wise training needs
assessment of GHC staff
b. To ensure that all MO should be able to
diagnose and manage leprosy and its
complications
c. To ensure that all HAs, MPWs be trained to i)
deliver and follow up of treatment and ensure
case holding, ii) suspect a case of leprosy, iii)
suspect a case of reaction and refer, iv) impart
health education
d. To ensure that all Block Extension Educators,
Anganwari Supervisors, Anganwari Workers,
Community Health Guides are sensitised on
leprosy.
e. To ensure that all IEC materials are available at
all PHCs, APHCs, SHCs, Dispensaries,
identified private sectors.
f. To ensure that learning materials are available
at all relevant health facilities.
Done
g.
h.
i.
Done
Done
Done by DTSTs
To a large extent done, partly by
DTSTs
To a large extent done during MLECs
To a large extend done during MLECs
Done, together with DTSTs
Done, together with DTSTs. However,
more emphasis should be put on how to
use materials
To ensure that MDT & supportive drugs are Done at most facilities, with exception
available at all health facilities
of several sub-centres.
To ensure that a simplified information system Done, with exception of several subis in place at all health facilities.
centres.
To ensure that a list of leprosy cases under Available at relevant health facilities.
treatment is available at every PHC.
b. Main responsibilities of Second Party, as formulated in MoU
Description
Findings
1. The second party will provide a Project Co-ordinator
after taking clearance from the GoI.
2. Second party will provide 24 DTSTs for 70 districts.
3. The Project Co-ordinator will inform the DLOs/CMOs
about the names and designations of the members of the
concerned DTST.
4. The Project Co-ordinator will send his monthly
advance tour programme to the SLO. The MOs of the
DTST will send their monthly advance tour plans to the
DLO of the concerned districts.
5. The support of the Second Party will include the salary
Done
23
Done
Done
Done
Done,
however
maintenance
of
and TA/DA of all staff of DTSTs, Project Co-ordinator
and his office. In addition, Second Party will provide
vehicles and meet their running costs, POL, and repair
and maintenance. Furthermore, Second Party will
support the SLO’s office for communication and
photocopier maintenance and meet all costs for 6monthly review meetings, Mid Term Review, Final
Evaluation, and production for learning materials if
required.
6. The DTST will facilitate the process of integration of
leprosy elimination services form NLEP into GHC
system, and in doing so contribute to NLEP’s goal of
elimination of leprosy.
7. The DTSTs will function as per the “National
Guidelines for involvement of DTST under NLEP”
circulated by GoI.
8. The DTSTs will work in close liaison with District
Leprosy Society of the district concerned, which will
mean regular meetings with CMO, DLO an DM
wherever required.
9. The Project Co-ordinator shall work in close liaison
with the State Leprosy Office, CMOs/DLOs, State WHO
Co-ordinator and Leprosy Division of GoI.
10. The Second Party shall provide no assistance in cash
or kind to any DLS, State Leprosy Society or to the First
Party, other than described in this MoU.
photocopier not fully financed.
Done (see chapter 4.2)
Done
DLS not functioning well, and DTST
do rarely have regular meetings with
DLS (see chapter 4.4)
Done
Done
C. Main general responsibilities as formulated in MoU
Description
Findings
1. The DTST will be in position for a period of three
years starting from 1st of January 2002.
2. First Party and Second Party will jointly organize
meetings to review the progress of the DTSTs once every
six months, where WHO State Co-ordinator and GoI will
also be invited.
3. A Mid Term Review will be planned by Second Party
for implementation by mid 2003, which should be
participated by First Party, Second Party and GoI.
4. An independent End Evaluation of the DTST Project
will be done in September 2004 by a team of
independent experts with invitation to WHO.
Done up to now
24
Done at a quarterly base
Done
Done
APPENDIX VI – REVIEW OF RECOMMENDATIONS MTE
Description
Findings
1. The review team recommends to embark, as soon as
possible, on a new training cycle for all cadres involved,
including DTST staffs.
2. The project co-ordinator, in collaboration with the SLO,
will select the contents and methodology of the training
courses.
3. The so-called Accompanied MDT should only be used
under strict conditions and not as a routine. The ANM
should always report to the PHC i.c. on the treatment
outcome.
4. The supporting characteristic of the DTST should be
made more obvious by a pro-active co-operation between
DLO an DTST. Indicators could be the fieldwork
programmes and the submitted annual plans.
Not fully implemented, training cycle still
going on.
They have been involved in identifying the
contents of training courses.
As far as could be observed during the
evaluation, Accompanied MDT is only used
in exceptional cases.
In general co-operation between most
DTSTs and DLOs is good and programmes
are made in co-ordination. However, some
DTSTs have the tendency to take over work
from the DLOs. Indicators are, however, not
used.
5. The DLO to participate in monthly Block Meetings, DLO and DTST often participate in the
which are organized by the CMO, and give his monthly meetings in most of the districts.
contribution, in co-operation with the DTST, to the NLEP
by concise remarks and questions. This, to inform the
CMO on relevant issues for later discussion with the DM.
6. Training materials should be demonstrated and used Training
materials
are
still
rarely
actively during training sessions as a support to sustained demonstrated, which hampers its use.
use later during daily practice.
7. Constraints in supervision activities by DTST (PC) and This has not been done formally. However,
NLEP (SLO) were recognized. It is recommended to informally most relevant stakeholders are on
complete the unfinished problem analysis and stakeholders board for integration.
analysis and also explore possibilities to involve other
cadres like the Regional Directors and Additional
Directors. Hence administrational and technical
commitment to integrated leprosy control could be
strengthened.
8. Given the sufficient capacity of the 24 DTS Teams it is Has been implemented.
recommended to increase the coverage of the project to the
whole state of UP.
9. It is recommended that the identified stakeholders (DLO, A monthly district meeting exists in which
CMO, DTST-MO, WHO consultant and any other member the DLO and DTST-MO participated.
of the DLS) should meet on a monthly basis to discuss However, no specific leprosy meeting takes
programme matters. The CMO, after being well informed place.
by the meeting, should hereafter meet the DM on program
matters.
10. It is recommended that the office of the DTST should Many DTSTs have their office close to or in
be accommodated in the DLO/CMO office.
the DLOs office. However, since DTSTs
cover 2 to 3 districts mostly they have
chosen one district from which they operate.
11. Whenever the prevalence or prevalence rate is used, The focus in the programme is strongly on
figures should also show case detection and case detection prevalence rate. As a result other indicators
rate.
are getting less attention. In most reports
case detection is also indicated.
25
APPENDIX VII - DISTRIBUTION LIST
Joint Secretary Health, Ministry of Health, Delhi, India
DDG (L), Government of India, Delhi, India
Principal Secretary Health, State Government of Uttar Pradesh, Lucknow, India
State Leprosy Officer, State Government of Uttar Pradesh, Lucknow, India
Project Co-ordinator, DTST Leprosy Project, Lucknow, India
AIFO, Bangalore, India
NLR Project Department, Amsterdam, The Netherlands
KIT, Leprosy Unit, Amsterdam, The Netherlands
NLR India Branch Office, Delhi, India
TLM South Asia, Delhi, India
TLMI London, UK
TLMI Evaluation & Monitoring Service, Apeldoorn, The Netherlands
SMHF, Japan
WHO Delhi
WHO SEARO
Team members End Evaluation
26