|
FTEL Aug 06・No. 21
NEPAL REPORT
Moving in the Right Direction
Leprosy-endemic Nepal still striving to reach the elimination goal.
AUTHOR: Dr. Bimala Ojha
| Dr. Bimala Ojha is director, Leprosy Control Division, Department of Health Services, Ministry of Health, Nepal |
In recent times, Nepal has witnessed a declining trend in both the leprosy prevalence rate and the new case detection rate. However, this decline was not fast enough to see the disease eliminated as a public health problem by the end of last year. As of 15 April 2006, the PR stood at 1.82.
A small landlocked country of 25 million people, Nepal is divided into five development regions and 75 districts. Nearly half (48.4%) of the population lives in the Terai (plains) region, which makes up 23% of the landmass.
The Eastern Developmental Region (EDR) continues to record the highest PR, and the Central Developmental Region (CDR) the largest number of new case detections. The Western Developmental Region (WDR) has consistently reported the lowest PR in the country.
Table 1 summarizes the disease trend over the last three years using national leprosy elimination program (NLEP) indicators.
Leprosy has remained highly focal, with the Terai region accounting for 82% of the country's caseload. Ten districts alone have half (51%) of the country's registered cases. In none of Nepal's 75 districts is the PR is over 5/10,000. Thirty-five districts have already reached the elimination level.
Treatment compliance has remained consistently good and completion rates reported for the year 2004/05 were 91% for multibacilliary cases and 94% for paucibacillary cases.
During the second quarter (16 November 2005 to 15 April 2006) the number of cases under treatment has come down by 5.3%. All the regions have shown a decline. This decline is most marked in the Mid-West Developmental Region (15.8%) and least evident in the CDR (0.05%).
Table 1: Disease trend over the last three years
|
2002/03 |
2003/04 |
2004/05 |
| NCDR |
3.24
|
2.84
|
2.4
|
| PR |
3.04
|
2.41
|
2.02
|
| MB(%) |
51.22
|
50.95
|
52.3
|
| Child(%) |
7.7
|
6.57
|
6.78
|
| Grade II DR(%) |
3.95
|
3.48
|
3.52
|
| Female(%) |
29.6
|
31.8
|
34.47
|
| Defaulter(%) |
5
|
2.4
|
0.89
|
|
NCDR: New case detection rate per 10,000,
PR: Prevalence rate per 10,000, MB (%): Proportion of MB cases among new cases, Child (%): Proportion of children among new cases, Grade II DR (%): Proportion of new cases showing Grade II Disability at detection. |
|
|
|
Source: Ministry of Health, Nepal
|
SERVICE DELIVERY
MDT services are integrated and have been delivered through all the peripheral health facilities of Nepal (188 primary health centers, 697 health posts and 3,129 sub-health posts) since 1987. The participation of hospitals in leprosy service delivery is sporadic and patchy. Referral centers run by international NGOs are providing routine diagnostic as well as referral services.
Outreach clinics ― both those of primary health centers and of the expanded program on immunization ― are not actively involved in leprosy patient care.
Over the years, the program has created a vast pool of trained manpower and every health facility has more than one trained person. However, most of the human resources developed and deployed are either unutilized or underutilized for want of adequate demand for their services and/or inadequate motivation amongst service providers.
A functioning network of supporting partners exists in Nepal. Periodic review meetings are held regularly at all levels. Supervision has been limited until recently to health facilities that are easily and safely accessible due to the security situation.
Nepal: leprosy is highly focal in its distribution
OBSTACLES
A centralized decision-making process further complicated by an ambiguous line of command is one of the impediments facing the program. Paradoxically, the program is heavily dependent on external support (in terms of money, material and people) from multilateral and bilateral agencies.
The low caseload and low demand for services are rendering integrated service delivery cost ineffective and making it increasingly difficult to sustain skills at the peripheral level. Motivation to do leprosy work among staff in general, and those working in hospitals in particular, is low.
Patient management tasks (including diagnosis and treatment of complications) largely go unsupervised. The quality of laboratory services is not satisfactory. IEC activities are neither needsbased nor area-specific.
Nepal: 35 districts have achieved elimination
Photo by Pamela Parlapiano |
Leprosy FACT
●A 2005 case validation study in Nepal found that one quarter of cases had been improperly diagnosed: wrong diagnosis (9%), re-registration (11%) and non-existent cases (6%).
Motivation among staff in general, and those working in hospitals in particular, is low.
FUTURE PLANS
The strategy of “early diagnosis and prompt treatment” will remain the same for the foreseeable future, with minor changes in the way that the strategy is being implemented. Perhaps rehabilitation work might be given higher priority in the coming years. Some of the activities under consideration include:
・Strengthen select health centers and hospitals in endemic regions to empower them to provide secondary-level care so that access to secondarylevel care improves;
・Undertake review of cases under treatment and delete all cases inappropriately registered, an exercise expected to bring down PR by 25% to 30% and which will hopefully minimize inappropriate registration in future;
・Evaluate leprosy training ― need, suitability of the current curriculum, effectiveness of training process and impact of training ― and draw up a plan for future training so as to make it needsbased, task-oriented and cost-effective. Medical colleges and other health-sector training facilities will be progressively involved in leprosy service delivery and training.
・Assess the impact of IEC activities and develop and implement area-specific plans;
・Centralize leprosy diagnosis in low endemic areas and limit this to health centers and hospitals to ensure quality diagnostic services. But health posts and sub-health posts in endemic districts will continue to diagnose cases and initiate treatment, as they do now, for quite some time;
・Promote a more democratic leadership style whereby major stakeholders proactively participate in planning and decision-making.
DUAL CHALLENGES
In conclusion, the leprosy control program in Nepal faces dual challenges. There is a need to reduce prevalence as early as possible to elimination levels. At the same time, the program has to ensure the availability of quality leprosy services as long as they are needed, and wherever they are needed, at a reasonable cost.
|
