Lepr Rev (2010) 81, 306–317

Integration of into GHS in : A Follow up study (2006–2007)

APARNA PANDEY & HARISH RATHOD Regional Leprosy Training & Research Institute, Lalpur, Raipur-492 001 (C.G.), India

Accepted for publication 30 September 2010

Summary In India leprosy services, were integrated into the General Health Services (GHS), in a phased manner, in different provinces, from 2001 to 2004. This study reports the findings from a follow-up operational research undertaken in 2006– 2007, to assess the level of integration, on predetermined indicators related to: referral services, training of health functionaries, availability of diagnosis, treatment, MDT dispersal and counselling guidelines in health facilities, recording and reporting by GHS staff, MDT stock management and involvement of health sub-centres in different Indian provinces. Nine provinces, 18 districts, 88 health facilities and 108 sub-centres were selected, by using multistage stratified random sampling techniques. Reverse integration, as reflected by the training and deployment of vertical staff in GHS, was also assessed. Data was collected by medical officers experienced in leprosy, with the assistance of state health functionaries, and recorded on separate schedules for health facility and sub-centre levels. The study also touched on the issue of client perception towards MDT services by interviewing 149 under treatment/cured leprosy cases (who had completed treatment within the last year), in the community with the help of local interpreters. Results showed wide variations across the selected provinces in various parameters. District leprosy nuclei were understaffed in 12 (66·7%) districts, and district hospitals were not working as referral institutions anywhere. The training status of medical officers and multi-purpose workers in leprosy was low in (6·9 and 22·4%), (26·3 and 14·5%), (19·7 and 40·9%) and Kerala (25·5 and 65·7%). MDT stock availability as per the National Leprosy Eradication Programme (NLEP) guidelines was not adequate in all provinces. Availability of patient counseling guidelines was nil/low in Kerala, Karnataka, West Bengal, Orissa, Rajasthan and Andhra Pradesh. The involvement of sub-centres, in case referral, recording and dispensing MDT was nil Kerala and Rajasthan and poor in Andhra Pradesh. Ninety percent of clients in Kerala and 38·0% in Andhra Pradesh and Madhya Pradesh did not get MDT in the nearest health facilities or sub-centres.

Correspondence to: Aparna Pandey, Flat 1C, Block P, Sourya Niloy Housing Complex, 1 Kailash Ghosh Road, Near Sitala Mandir, Kolkata 700008, (WB), India (Tel: þ9-033-24943326; Mob: 09331662007; e-mail: [email protected], [email protected])

306 0305-7518/10/064053+12 $1.00 q Lepra Integration of Leprosy in GHS in India 307 Background Information

India achieved the goal of leprosy elimination as a public health problem at national level in December 20051,2 as per the resolution passed in the World Health Assembly 1991.3 In view of the declining leprosy case load, and as a part of global strategy,4 leprosy services have been integrated into the General Health Services (GHS) in different provinces of India, in a phased manner during 2001–2004.5 Integration of the vertical leprosy control programme into the GHS required radical changes and modifications to provide leprosy services in the community nearer to patients’ homes in a sustainable manner, without compromising the quality of care.6,7 The staff of the vertical leprosy programme were deployed into the GHS after proper training. However, different provinces vary widely, not only in disease endemicity,8 but also in their health situation and socioeconomic development.9–11 Therefore, the integration process was not likely to be uniform in all provinces and required continuous monitoring and evaluation, more so in the transitional post-integration period, which also differed among provinces, which might lead to a setback in the ultimate aim of the eradication of leprosy. The Directorate General of Health Services of the Government of India undertook an operational research project in 2004 to assess the actual level of integration, using defined indicators related to various components viz. the formation of district nuclei, posting of ‘vertical’ leprosy staff into the GHS, the training of GHS and vertical staff, availability of MDT in health facilities, recording and reporting of leprosy, maintenance of MDT stocks as well as the involvement of sub-centres in leprosy care. The study results have already been published earlier.12,13 A follow-up study was undertaken to further assess the level of integration of leprosy services into the GHS, using similar methodology during 2006–2007, and a component of client perception towards MDT services was included. The present analysis attempts to identify province-wise specific deficiencies and suggest interventions appropriate to local situations to improve the quality of the programme.

Materials and Methods

The methodology adopted has been similar to one undertaken in the earlier study, and has been explained in detail elsewhere,12,13 however, a brief description is given below. Of the 29 Indian provinces (called states in India), nine (Andhra Pradesh, , Kerala, Karnataka, Madhya Pradesh, Orissa, Rajasthan, Tamil Nadu and West Bengal), were selected by the Directorate General of Health Services (DGHS), Government of India, with the background of health and socio-economic status and leprosy endemicity of the province. Thereafter in the second stage, from each of the nine provinces, two districts were identified randomly for the survey by the nodal agency i.e. Regional Leprosy Training & Research Institute (RLTRI), Raipur. In the third stage of sampling, health facilities (i.e. health institutions with a medical officer in position) were identified. Five health facilities, including the District Hospital (DH) and another four were randomly identified from each of the 18 selected districts. This included one Community Health Centre (CHC), two Primary Health Centres (PHC) and one Urban Health Centre (UHC) or Urban Hospital (UH). However, in Andhra Pradesh, instead of two, only one PHC from each district could be visited due to operational problems. 308 A. Pandey and H. Rathod Thus in total 88 health facilities, including 18 District Hospitals, 18 CHC, 34 PHCs and 18 UHCs/UHs were surveyed from the nine selected provinces. Again, as with the earlier study,12 two sub-centres (SC) were randomly selected from each of the selected PHCs and CHCs. For Andhra Pradesh, three sub-centres were selected from each of the PHCs and CHCs. Thus from each province 12 sub-centres, and from the nine provinces 108 sub-centres were surveyed. In addition for the present study, client perception towards MDT services was also studied by interviewing 10–20 current and old (who were either taking MDT or had completed MDT within one year of the survey), leprosy cases in the community.

DATA COLLECTION

The data were collected from each province by one medical officer (MO) trained in leprosy, with the help of assisting staff from provincial health departments, and local interpreters. Surveys of 15 days’ duration in each province, was undertaken in December 2006 and January 2007, to collect the required data. Information collected was recorded on three sets of specially designed pre-tested schedules, namely for the health facility, for the sub-centres and for client perception. Survey techniques included interviewing the available health staff, scrutinising the records/reports and checking the stock of MDT on the spot. Combined values for all the indicators were obtained by compiling indicators from all provinces (Table 1). In sub-centre areas where there were no cases, multi-purpose workers (MPWs) and health supervisors (HSs) were asked certain questions and their records were checked to assess their possible role in leprosy case management. For assessing clients’ perception towards MDT services, their interview was undertaken in the community on various aspects listed in Table 3, with the help of local interpreters. MS excel was used for calculation of integration indicators. To show the inter-provincial variations (Tables 2 and 3), individual indicators were further clubbed into following categories: INTEGRATION STATUS is reflected by the following categories (Table 2):

I.1. Referral support included the following sub-categories: * A. Formation of District Leprosy Nucleus (DLN): As per guidelines mentioned under Project Implementation Plan.5 * B. Involvement of the district hospital (DH): As this was not included in the pre- determined indicator list, information was gathered separately during visits to the hospitals. I.2. Training of Health functionaries consisting of the following sub-categories: * A. Training level of medical officers (MO): They are crucial in confirming the diagnosis. * B. Training level of multi-purpose workers (MPWs): They are important in the identification of suspected cases, referral and treatment continuation or case holding of confirmed cases. I.3. Involvement of Health facilities (HF): Suspected cases from the periphery are sent for diagnosis to one of the health facilities, which are mainly responsible for providing leprosy case management services. Three sub-categories were grouped under this category: * A. Health facilities where all medical officers diagnose leprosy cases * B. Health facilities with daily availability of MDT Integration of Leprosy in GHS in India 309

Table 1. Values of Compiled Indicators (Integration & Reverse Integration) for Indian Provinces (2006–2007)

Value of Indicator Number included (category) Se No Name of Indicator (category) in study (n) Number (%)

1 Districts where district nucleus is formed as 18 4 (22·2) per Project Implementation Plan (PIP) guidelines 2 Health facilities where vertical staff were delivering 88 47 (53·4) General Health Care (GHC) 3 GHS staff trained in Leprosy † Medical officers 877 320 (36·5) † Health Supervisors 174 104 (60·5) † Multipurpose Worker 793 533 (67·2) † Media staff 15 12 (80·0) 4 Vertical staff trained in GHC delivery 80 41 (50·3) 5 Health facilities where leprosy diagnosis is done † By all Medical Officer (s) 88 60 (68·2) † By specific Medical Officer 14 (15·9) 6 Health facilities where leprosy treatment is available † On daily basis 88 72 (81·8) † On fix days 12 (13·6) 7 Health Facilities where MDT is dispensed † With other Medicines 88 49 (55·7) † Separately 24 (27·3) 8 Health Facilities having MDT stocks as per current 88 Govt. of India guidelines † MB (Adult) 13 (14·8) † MB (Child) 5 (5·7) † PB (Adult) 8 (9·1) † PB (Child) 3 (3·4) 9 Health Facilities where GHS staff is involved in reporting 88 40 (45·5) 10 Health Facilities having counseling guidelines for community 88 37 (42·0) 11 Health sub-centres involved in leprosy care † Had leprosy cases in their areas 108 65 (60·2) † Referring suspects 65 37 (56·9) † Distributing MDT 65 45 (69·2) † Keeping Patient cards 65 36 (55·4) 12 Client perception towards MDT services 149 † Getting MDT to nearest SC or PHI 125 (83·9) † Getting free MDT 148 (99·3) † Health staff availability at the time of visit 142 (95·3) † Satisfied with health staff behaviour 146 (95·0)

* C. Health facilities where MDT blister packs are dispensed from a common pharmacy I.4. Availability of counseling guidelines in the health facilities I.5. Involvement of GHS staff involved in recording and reporting of leprosy cases I.6. MDT blister-pack stock management for each category separately * MB-adult * MB-child * PB-adult * PB-child 1.7. Involvement of Sub Centres in providing leprosy care had three components: * A. Case referral * B. Record maintenance (Patient cards) 310 .Pne n .Rathod H. and Pandey A.

Table 2. Status of Integration Leprosy services into GHS in Indian Provinces (2006–2007)

Names of Province

Indicator AP CG Karnataka Kerala Orissa MP Rajathan TN WB

Referral support (I.1) † A. DLN formation 00·0 00·0 00·0 50·0 00·0 100·0 50·0 00·0 00·0 † B. Involvement of DH 00·0 00·0 50·0 100·0 100·0 0·00 00·0 00·0 00·0 Training of GHS in Leprosy (I.2) † A. Medical Officer 06·9 98·1 60·0 25·5 70·0 26·3 19·7 45·0 30·0 † B. MPW 22·4 93·3 100·0 65·7 94·2 14·5 40·9 93·0 88·0 Involvement of CHC &PHC (PHIs) (I.3) † A. All Medical Officers diagnosing 75·0 70·0 90·0 50·0 70·0 10·0 70·0 90·0 90·0 † B. Daily treatment availability 62·5 100·0 100·0 60·0 90·0 40·0 100·0 90·0 90·0 † C. MDT dispensed with other medicines 50·0 50·0 70·0 10·0 90·0 20·0 30·0 90·0 90·0 Availability of Counseling guidelines at health facility (I.4) 37·5 100·0 10·0 00·0 20·0 90·0 20·0 90·0 10·0 Recording and reporting by GHS (I.5) 00·0 30·0 40·0 10·0 90·0 20·0 50·0 60·0 100·0 MDT Stock availability as per guidelines (I.6) † A. MBA 37·5 20·0 30·0 00·0 00·0 20·0 20·0 10·0 00·0 † B. MBC 12·5 20·0 00·0 00·0 00·0 00·0 20·0 00·0 00·0 † C. PBA 00·0 30·0 00·0 10·0 20·0 00·0 00·0 20·0 00·0 † D. PBC 12·5 00·0 00·0 10·0 00·0 00·0 00·0 10·0 00·0 Involvement of SC (I.7) † A. Case referral 30·0 66·6 58·3 00·0 62·5 66·7 00·0 73·6 00·0 † B Recording 20·0 100·0 50·0 00·0 100·0 41·7 00·0 93·6 90·9 † C. Dispensing MDT 20·0 50·0 41·7 00·0 62·5 41·7 00·0 87·5 100·0

AP ¼ Andhra Pradesh, CG ¼ Chhattisgarh, MP ¼ Madhya Pradesh, TN ¼ Tamil Nadu, WB ¼ West Bengal. Table 3. Reverse Integration Indicators and Client perception towards MDT in Indian Provinces (2006–2007)

Names of provinces

Indicator AP CG Karnataka Kerala Orissa MP Rajasthan TN WB

Health Facilities with deployment of Vertical staff (RI.1) 6 (75·0) 7 (70·0) 3 (30·0) 9 (90·0) 5 (50·0) 7 (70·0) 1 (10·0) 4 (40·0) 5 (50·0) No of Vertical staff included in study 6 9 3 17 8 12 1 11 13

No (%) of Vertical staff trained in GHC (RI.2) 0 (00·0) 9 (00·0) 2 (66·7) 17 (100·0) 0 (00·0) 4 (33·3) 0 (0·00) 9 (81·8) 0 (00·0) India in GHS in Leprosy of Integration Client perception towards MDT AP CG Karnataka Kerala Orissa MP Rajasthan TN WB

No of clients included in study 14 (100·0) 18 (100·0) 25 (100·0) 10 (100·0) 16 (100·0) 25 (100·0) 11 (100·0) 16 (100·0) 14 (100·0) Getting MDT to nearest SC or PHI 10 (71·4) 18 (100·0) 25 (100·0) 1 (10·0) 13 (87·5) 18 (72·0) 11 (100·0) 14 (87·5) 14 (100·0) Getting free MDT 13 (92·7) 18 (100·0) 25 (100·0) 10 (100·0) 16 (100·0) 25 (100·0) 11 (100·0) 16 (100·0) 14 (100·0) Health staff availability at the time of visit 13 (92·7) 17 (94·4) 25 (100·0) 10 (100·0) 16 (100·0) 24 (96·0) 8 (72·8) 15 (93·8) 13 (92·9) Satisfied with health staff behaviour 13 (92·7) 18 (100·0) 25 (100·0) 10 (100·0) 16 (100·0) 25 (100·0) 10 (90·9) 15 (93·8) 14 (100·0)

AP ¼ Andhra Pradesh, CG ¼ Chhattisgarh, MP ¼ Madhya Pradesh, TN ¼ Tamil Nadu, WB ¼ West Bengal. 311 312 A. Pandey and H. Rathod * C. Dispensing MDT (second dose onwards) RI. Reverse Integration status is reflected by following categories (Table 3) RI1. Training of vertical staff. RI2. Health facilities with the involvement of vertical staff in providing General Health Care (GHC) CP. Client perception towards MDT (Table 3) CP1. Getting MDT from the nearest SC or PHI (CHC or PHC) CP2. Getting free MDT CP3. Health staff availability at the time of the visit to health institutions CP4. Client satisfaction with health staff behaviour.

Results

The study relates to 29 Indian provinces. The survey covered nine provinces (population 525,236,669) with a prevalence rate (PR) varying from 0·20/10 000 in Rajasthan, to 1·45/10 000 in Chhattisgarh.8 Eighteen randomly selected districts covered a population of 45,065,977. The population ranged from 933,981 in Mahasamund District in Chhattisgarh Province, to 5,489,100 in Jaipur District in Rajasthan. The prevalence rates of the districts ranged from 0·14/10 000 in Dausa District of Rajasthan, to 3·64 in Bargarh District of Orissa. Table 1 shows the values of the compiled indicators for the entire province. As observed only in four districts (22·0%), District Leprosy Nuclei (DLN), were formed as per the Project Implementation Plan (PIP) guidelines.5 Most of the remaining districts had a deficiency of one or two staff members, mostly physiotherapists. The training levels of lower level staff in peripheral health institutions (both GHS and vertical), were over 50·0%. Daily availability of MDT was 81·8%, diagnosis by all medical officers was 68·2% and dispersion of MDT from common pharmacies was seen in 55·7% of health facilities. MDT stock availability was quite low, as the values for different categories ranged from 14·8 to 3·4%. The involvement of sub-centres in leprosy care for different functions varied from 55·4 to 69·3%. The inter-provincial variations in integration (Table 2), shows that the involvement of district hospitals in leprosy work was 100·0% in Kerala and Orissa, 50·0% in Karnataka and nil in other provinces. The training of medical officers was highest in Chattisgarh (98·1%) and lowest in Andhra Pradesh (6·9%). The training status of multi-purpose workers (MPWs) was highest in Karnataka (100·0%), and lowest in Madhya Pradesh (15·5%). The involvement of peripheral health institutions (PHI) such as CHC and PHC in diagnosis and treatment of leprosy and MDT blister pack distribution was higher in Tamil Nadu, Karnataka and Orissa and lower in Madhya Pradesh. The involvement of GHS staff in recording and reporting was 100·0% in Orissa and West Bengal, and zero in Andhra Pradesh. MDT stock availability as per the national guidelines was poor in all the states. The involvement of sub-centres (SC) was high in Tamil Nadu, Chattisgarh and Orissa and zero in Rajasthan and Kerala. Training and deployment of vertical staff in GHS (Table 3) was highest in Kerala and Chattisgarh (100·0%) and lowest in Rajasthan, Orissa, Andhra Pradesh, Rajasthan and West Bengal (0·0%). Integration of Leprosy in GHS in India 313

CLIENT (CONSUMER) PERCEPTION

Client (consumer) perception towards MDT services was assessed by interviewing 149 clients. Of them 120 (80·5%), were under treatment and the rest had completed treatment within the last year. One hundred and one (67·8%) of them belonged to the MB category, with an average age varying from 30 to 40 years in different provinces, males constituting 68·5%. Of the total 25 cases who were not getting MDT from their nearest sub-centre/health facility, nine were from Kerala and seven from Madhya Pradesh. Only one case in Andhra Pradesh had to pay for MDT. The majority of cases (98%) were satisfied with the behavioural aspects of health staff – the majority (94·6%) met the health staff at the time of their visit to the health facility.

Discussion

Integration of leprosy aims at improving the efficiency and effectiveness of leprosy diagnosis and treatment services by bringing services closer to the community. Ensuring quality services requires early and correct diagnosis, timely and complete treatment, patient and family counseling, disability prevention and care, increasing community awareness for early self-reporting for diagnosis, uninterrupted and adequate supply of MDT blister pack stocks at all levels as well as continued vertical backup for technical and logistical support, supervision and referral.7,14

REFERRAL SUPPORT

The guidelines of the National Leprosy Eradication Programme (NLEP), India emphasises that strong referral back-up for leprosy services in an integrated set up, is to be provided by the district leprosy nucleus and the district hospital. The district leprosy nucleus consists of experienced personnel from the vertical programme for backup support on clinical aspects, supervision, monitoring, logistic management and administration,14 whereas the district hospital will provide specialist advice and care for problems in diagnosis, treatment, management of reactions and medical rehabilitation. In our observation, all the districts had functional district leprosy nuclei, but only four (22·2%) had as per the guidelines laid down under the Project Implementation Plan (PIP), by the National Leprosy Programme.5,14 The findings are a deterioration from earlier reports.12 Except for Andhra Pradesh, in most provinces there was deficit of staff of various categories. Physiotherapists were inadequate in the high endemic states of Chattisgarh, Orissa and West Bengal, whereas medical officers were in short supply in Kerala. In the low endemic province of Karnataka, paramedical workers (PMWs) were lacking. In recent years greater emphasis has been laid on the disability prevention and medical rehabilitation (DPMR) component, but still a shortage of physiotherapists was observed. This can have an adverse impact on the programmes in endemic districts. In contrast, Andhra Pradesh had a surplus of staff in the district leprosy nuclei. This was mainly due to problems in the cadre allocation of staff. Vertical staff, by virtue of their seniority, were posted in district headquarters or in the higher level of health facilities like CHCs. Nowhere were district hospitals performing the role of referral institutions, as had been expected post-integration.7 The majority (75%) were not involved in leprosy care at all, 314 A. Pandey and H. Rathod whereas a smaller proportion (25%) were engaged in the diagnosis and treatment of uncomplicated cases – a function which could well be performed by the lower level of health facilities.

TRAINING OF GHS IN LEPROSY

Low training levels of medical officers (36·5%) reported in the study is a cause for concern. Even the training levels of multi-purpose workers (67·2%) were lower than reported earlier;12 this may be due to a lower resource allocation for leprosy in favour of other emerging, and more important health issues. Analysis of province-wise data showed that the training level ranged from 98% in Chhattisgarh to less than 7% in Andhra Pradesh, Rajasthan, Kerala, Madhya Pradesh and West Bengal. Most of the medical officers included in the present study were posted in the PHIs (CHC & PHCs), where they are supposed to play a crucial role in confirming a diagnosis. Discrepancies in the training levels of medical officers and the availability of diagnosis by all medical officers, raises questions about the effectiveness of training. In Andhra Pradesh, in spite of the low levels of training of medical officers, diagnosis availability in peripheral health institutions was much higher, which may pose a risk of the wrong diagnosis being made. As also reported, during the Modified Leprosy Elimination Campaign (MLEC) IV that was undertaken in India, 20% of leprosy cases were wrongly diagnosed by medical officers.15 In contrast, in Chhattisgarh and Madhya Pradesh, training levels were higher than the availability of diagnosis in peripheral health institutions. Similarly in The Congo, researchers also failed to find a relationship between training and the diagnosing ability of nurses.16 The training level of multi-purpose workers was also quite low in Andhra Pradesh and Madhya Pradesh. These workers, being much closer to the community, play an important role in the identification and referral of suspected cases. However, at this level also, the relation between training of multi-purpose workers and the involvement of the SC is not clearly evident. Thus it can be inferred that the trained manpower is crucial to the success of integration, yet training alone without supportive supervision, is unlikely to produce the intended outcome.

INVOLVEMENT OF PERIPHERAL HEALTH INSTITUTIONS (PHIS) IN LEPROSY CARE

In an integrated set up, it is expected that diagnosis of leprosy should be done, by all medical officers. In the study the finding was observed in 68·2% of health facilities. The figure is marginally lower than reported earlier.12 However, in the present study, in another 15·9% of health facilities, diagnosis was undertaken by a specific medical officer - either a dermatologist or someone trained in leprosy – and this pattern was seen mostly in Kerala and Madhya Pradesh. In most provinces the daily availability of treatment was higher than the diagnosis by all medical officers, and these observations are in accordance with others’ findings.16 Diagnosis by all medical officers was more common in Tamil Nadu and West Bengal, whereas the daily availability of MDT was 100% in Chhattisgarh, Karnataka and Rajasthan. However, the overall involvement of PHIs on all three components, i.e. diagnosis, treatment and distribution of MDT, was at its maximum in Tamil Nadu and West Bengal. MDT supply was poor in all the provinces. In only a very few health facilities was MDT stock adequate, as per the guidelines. This had earlier been identified as a weak link in the programme.12,13 Integration of Leprosy in GHS in India 315

AVAILABILITY OF COUNSELING GUIDELINES

Patient and family counseling is one of the most important components of leprosy care, therefore health facilities are expected to keep to the guidelines which help them impart health education to clients and their families. Only a few provinces like Chhattisgarh, Madhya Pradesh, and Tamil Nadu were found to have these guidelines in place in the majority of their health facilities. In low endemic provinces like Kerala, Karnataka and Rajasthan low or non-availability of proper counseling may have a negative impact on the voluntary reporting of cases.

INVOLVEMENT OF GHS IN RECORDING AND REPORTING

The availability of simplified information system (SIS) formats17 was universal in all health facilities.18 However, involvement of GHS in recording and reporting was nil or low in Andhra Pradesh, Karnataka and Kerala. In these provinces, recording and reporting was mostly done by re-deployed vertical staff who were unwilling to hand over the jobs to the GHS. Similar observations have been made by others,18 and West Bengal was the only state where leprosy reporting was done by GHS staff in all the health facilities.

INVOLVEMENT OF SUB-CENTRES

The involvement of sub-centres was 55% to 60% for different functions, which is an improvement over the earlier report.12 Province-wise data showed that in Kerala and Rajasthan none of the sub-centres were involved in leprosy work, whereas Tamil Nadu reported a higher rate of involvement for all categories of work; Chhattisgarh and Orissa too had better involvement of sub-centres. In the present study, most of the provinces with higher training values of multi-purpose workers had a higher involvement of sub-centres too. However, in West Bengal, in spite of the high training values of their multi-purpose workers, they were not involved in the identification of suspected cases, which again raises questions about the ability of training to improve the skills of MPWs. During MLEC IV, the proportion of under-diagnosis was 15·0% mainly due to many suspected cases being missing at community level.16 Contrarily, in Andhra Pradesh and Madhya Pradesh, in spite of the low training levels of multi-purpose workers, they were engaged in case referrals from sub- centres to PHCs. There is a need to undertake operational research to reduce ‘under suspecting and over reporting’ of those suspected of having leprosy by untrained MPWs.

REVERSE INTEGRATION

Integration also requires the re-deployment of ‘vertical’ staff in the GHS after proper training, where they are expected to work as GHS staff delivering general health care (GHC). A few vertical staff are retained at district headquarters to work under the district leprosy nucleus. In Table 1, the compiled values from all the provinces show that more than 50% of the vertical staff were trained, and that about 50% of health facilities of the GHS had these staff. Province-wise data show a higher level of reverse integration (as reflected by the higher training and re-deployment of vertical staff), in Kerala and Chhattisgarh and also in Tamil Nadu, whereas other provinces were lagging behind. In Andhra Pradesh and Orissa, untrained 316 A. Pandey and H. Rathod vertical staff were posted into health facilities as part of a structural integration, where they were engaged in leprosy work, mostly recording and reporting.

CLIENT PERCEPTION TOWARDS MDT SERVICES

Universal availability of MDT, and higher satisfaction of clients in the present study may be due to the inclusion of ‘under treatment’ and treated leprosy cases. More detailed investigations are required to explore the issue further. However, the observation made in a few provinces like Kerala and Madhya Pradesh that a large number of cases had to travel to distant health institutions to get their MDT, is not in line with the basic spirit of integration, and needs to be corrected by better involvement of peripheral health institutions and sub-centres.

Conclusion

Wide variations across the provinces were observed in various parameters used to assess the level of leprosy integration into the GHS. Under-staffed district leprosy nuclei and scarcity of physiotherapists was evident in high endemic provinces, and district hospitals were not functioning as tertiary care institutions. The training status of GHS staff in leprosy was low in Andhra Pradesh, Madhya Pradesh, Rajasthan and Kerala. Involvement of peripheral health institutions in diagnosis, treatment and the dispensing of MDT was low in Madhya Pradesh. Counseling guidelines, especially in low endemic states like Andhra Pradesh, Kerala and Rajasthan, need strengthening. The involvement of sub-centres needs improvement, especially in Andhra Pradesh, Kerala and Madhya Pradesh. The training and involvement of vertical staff in GHS was nil in Andhra Pradesh. Greater involvement of peripheral health institutions (PHIs) in the management of MDT stock was needed in all the provinces. Lastly, but most important there is need for clear instructions, closer monitoring and supportive supervision at each level, district downwards, more so for PHI and sub-centre, for successful integration.

Acknowledgements

The authors are grateful to the officers of the participating institutions for their help in data collection. We also convey our sincere thanks to the State Health Authorities, specially State Leprosy Officers, District Leprosy Officers, Medical Officers, PHC and vertical staff without whose co-operation this study would not have been successfully completed. We also wish to express our deep sense of gratitude to the Central Leprosy Division for providing all the necessary guidance and support needed for the study.

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