Management Information Systems Coordinator,
DANLEP, Tamil Nadu
Leprosy control in India
The Government of India started the National Leprosy Control Programme in 1955 with the objective of controlling Leprosy with help of Dapsone. It was redesignated as National Leprosy Eradication Programme (NLEP) in 1983 as a centrally sponsored scheme, after Multi-Drug Therapy MDT became available for effective treatment of Leprosy. In 1991, WHO and its member States committed themselves to eliminate Leprosy as a public health problem by the year 2000. This commitment vowed to bring down the Leprosy cases below one case per 10,000 population. Government of India’s fight against Leprosy is now being supported by organizations such as WHO, World Bank, DANIDA and many other international Non Government Organisations (NGO). In India itself, NGOs have played a key role in leprosy control. For example, there are now about 285 NGOs actively involved in running several leprosy related services through the length and breadth of the country. Impact of the programmes of the governmental and non-governmental agencies has indeed been remarkable and the second section which discusses the trends in leprosy prevalence bears testimony to this assertion.
Trends and Differences in Leprosy Prevalence in India
When leprosy control programme in India was redesignated as National Leprosy Eradication Programme in 1983, the prevalence rate for India stood around 57 per 10,000 population working out to a total patient load of about 4 million cases. The national prevalence rate has come down to 5.2 per 10,000 population by March 1999 and patient workload was slashed to a total of approximately less than a million leprosy affected individuals (LAIs). However, statistics on leprosy prevalence rates are not accurate and the estimates of prevalence vary. In spite of the impressive decline observed in India, one disturbing fact is that these constitute a whopping 60 per cent of the total number of LAIs globally recorded. Out of the 0.5 million total LAIs in India, 70 per cent of the LAIs are concentrated in the states of Bihar, Uttar Pradesh, West Bengal and Orissa and Madhya Pradesh alone. Bihar alone has the dubious distinction of having about 32 per cent of recorded LAIs in India. The state of Punjab, Nagaland and Haryana have been able to reach the national target of reducing prevalence rate to 1 per 10,000 population.
In April 1986, by a bilateral agreement between Govt. of India and Govt. of Denmark, Danish International Development Assistance (DANIDA) working together with the National Leprosy Eradication Programme (NLEP) in India, called DANLEP with a multi-pronged approach to leprosy eradication. The major strategy followed by DANLEP has been to implement activities that were strongly rooted in the community and which involved the LAIs, their families, leprosy and general health staff and the community at large. DANLEP supported at State/district level in India: at district level, eight pilot districts viz. Gwalior, Durg, Rajnandgaon, Cuttack, Sambalpur, South Arcot, Salem and Madras; at the state level, Madhya Pradesh, Orissa, and Tamil Nadu;. Danida extended material and financial support for the programme including the training of leprosy programme personnel, monitoring and evaluation of the programme as well as the necessary logistical support. In the meantime, the collection, storage and manipulation of geographic information have undergone a revolution with the development and widespread availability of GIS software. Realizing the vast potential of the GIS technology and in order to take advantage of it for its programme planning, monitoring and evaluation needs, Danida decided to train its Management Information Systems Officer in this new technology. The present paper is an effort to provide a brief review of DANIDA’s use of GIS in the planning, monitoring and evaluation of the National Programme for Eradication of Leprosy in India. As the purpose here is to demonstrate its usefulness as a tool in policy formation, decision making and resource allocation, we have restricted our presentation to only one state in which DANIDA has been working viz., Tamil Nadu.
Geographical Information Systems and Leprosy Programme
Application of GIS for managing the leprosy programme’s service statistics became possible as a result of several developments:
- Availability of a reliable and regular system of data generation made possible by years of systematic and careful work in designing the system by DANIDA and the sincere and dedicated work of the field staff of the NLEP who meticulously maintained the records of the services provided by them with a detailed data on case load, deformities, age and sex profile and type of leprosy.
- Availability of survey of India maps for various political units up to the village level.
- Generous funding by DANIDA for acquisition of digitizing equipment, plotters and other infrastructure for the use of GIS.
- Inexpensive availability of software for application of GIS technology and its user friendliness and versatility for use in a wide range of software and hardware platforms.
- Service Statistics and GIS technology
As an illustrative example of the use of GIS technology in health care delivery programmes, we will see how the programme – generated service statistics are being used profitably. Instead of looking at a large set of numbers and trying to make sense of the numbers, depiction of these numbers by the use of maps allows us to get a three dimensional view- time, space and indicators for programme planning, monitoring and evaluation. Simply, to quote the one liner of Yogi Berra, a famous base ball coach in the American sports scene in the recent past, “You can see a lot just by lookin”.
Data for Tamil Nadu from the programme statistics:
Service statistics system designed by the programme collects and compiles data on the following indicators, among others, for various time periods and geographic units. In Tamil Nadu’s case, the following indicators have been stressed:
- Prevalence Rate per 10,000 population (PR)
- New Case Detection Rate (Annual)
- Multi-bacillary (MB) cases among new cases . (MB cases are considered to have a higher probability of transmitting the disease than the Pausi Bacillary (PB) cases)
- Single lesion cases among new cases detected. (Single lesion cases reflect the impact of the programme’s IEC package on self-assessment of early symptoms of the disease as well as the diligent work of leprosy programme personnel. It is to be noted that the disease is easily treatable in its early stage when usually only a single lesion will appear)
- Cases of children under 14 years of age (this is denoted as ‘child cases’ in the jargon of the leprosy programme personnel usually an indicator of the efficiency of the school surveillance system).
- Grade 2 deformity among new cases, which is an indicator for assessing the case load for rehabilitation programmes such as organization of surgery camps.
Figure 1: Prevalence Rate of Leprosy per 10,000 population in Tamil Nadu, Aug. 2000
For example, Figure 1 presents the prevalence rate of leprosy in the 29 districts in August 2000. It can be seen that the prevalence rate per 10,000 varies from a low of 1 in the Nilgiris to the highest rate of 8.4 in the Namakkal district. Maps have been colour coded in such a way that districts with low levels of prevalence are green -shaded and those with the highest rates are red -shaded. Further insights into the factors determining the prevalence rates can be assessed by preparation of maps for theoretically related indicators appropriately colour coded for examining the visual correlations between prevalence rate and the chosen variables.
In order to grasp the information about the availability and accessibility of health facilities in various districts of Tamil Nadu, location of government hospitals, primary health centers, voluntary reporting centers and other health care agencies including facilities run by non-governmental organizations as depicted in Figure 2.
Figure 2: Location of Health Facilities in Kancheepuram District, Tamil Nadu, Jan. 2000.
Juxtaposition of this map with that depicting the prevalence rate will reveal the presence of any association between location of health facilities and prevalence rates and might suggest guidelines for building new health facilities and allocation of resources in order to maintain a regional balance with in the region under study.
Besides the data generated by the service statistics, periodically special surveys have been conducted to focus on a particular aspect of the programme. One such survey, for example, explored the feasibility of implementing a slight modification of the leprosy elimination programme in the Tirunelveli district. This experimental programme was called the ‘Modified Leprosy Elimination Campaign’ (MLEC). Figures 3(a) and 3(b) present the distribution of leprosy cases detected in this campaign by the severity of the manifestations at the time of detection. Cases have been classified as ‘single lesion cases’ (SSL), pausi bacillary (PB) and multi bacillary (MB). The distribution of the type of cases has been presented for Rural areas (in Fig. 3(a)) and urban areas (in Fig. 3(b)). A comparison of these two figures reveals that in several locations in the rural areas, a large number of SSL cases have been detected while only in one location in urban areas they were detected. A possible explanation could be the IEC strategy to enlighten the people on the early symptoms of the disease has been successful in the rural areas while it did not produce an impact in the urban areas.
Figure 3(a) Rural
Figure 3(b) Urban
Distribution of Leprosy Cases by typewise in Rural and Urban areas of Tirunelveli district detected during the special survey, Modified Leprosy Elimination Campaign during Jan. 2000
Summary and Conclusion:
In the foregoing pages we have presented an example of the applications of GIS software in the National Leprosy Elimination Programme (NLEP) as implemented in Tamil Nadu. The paper has demonstrated the usefulness of the software for Health Care Programmes in general and in Leprosy Programme in particular for the purpose of Programme Planning and Evaluation.
The worth of GIS as an effective tool for the policy formation and deployment of resources has been eloquently demonstrated.
I should not fail to acknowledge the encouragement provided by Ms.Nanda Paithankar, Monitoring Adviser, DANLEP, New Delhi and the assistance provided by Dr. N. Murugesan SPC, DANLEP, TN. I gratefully thank Dr. S. Gunasekaran, HOD, Sociology, Pondicherry University for his support in producing this write-up.