N L E P

POID Pilot ProjectEast Godavari District

A Joint Initative of Government of Andhra Pradesh and FAIRMED

Rural India Self Development Trust

90-1-5/1, Swaraj Nagar, A. C. Gardens, Rajahmundry – 503 101,

(A. P.), INDIA. Ph: 0883-2425367 E-mail: risdtindia@gmail.com

Update January 2013

2 3

Implementation of the Prevention of Impairments and Disabilities (POID) Program in East Godavari is possible with the support of the

following patrons:

NLEP, State and District Leprosy Program for the coordinating support

District Collector, East Godavari for regularly reviewing the program and for unflinching support

FAIRMED for the financial and technical support

And finally, all the Persons Affected by Leprosy, whom the program serves

4 5

From DISPEL to POID

The Government of Andhra Pradesh (GoAP) has been

implementing the Disability Prevention and Education

in Leprosy (DISPEL) program in six high leprosy preva-

lent districts since 2000-2001. In East Godavari, Rural

India Self Development Trust (RISDT) in partnership with

the District and State Leprosy Program initiated the pro-

gram in 2004 to prevent new deformities and manage

existing deformities among PALs. The project support-

ed the NLEP program in reduction/prevention of dis-

abilities and direct provision of care. DISPEL provided

medical kits and MCR footwear to supplement govern-

mental supplies and support supply chain streamlining.

Till 2010, the program was able to provide services to

over 40,000 PAL; manage ulcers among 24,000 per-

sons; extend physiotherapy services to 30,000; supply

MCR footwear to over 21,000; treated over 7,000 PAL

through in-patient care and 401 PAL underwent surgical

corrections.

In 2009, FAIRMED, the donor of the program evaluated

the DISPEL program across the six districts including the

work of RISDT and the evaluation findings suggested -

the services of DISPEL were found highly satisfying to

PALs and appreciated by the NLEP staff. The project

demonstrated impressive successes in reducing the bur-

den of the disability in the project areas. The evaluation

recommended continuation of DISPEL for anothertwo

years during which time, the project would work towards

encouraging self-care by the PAL and promote the inte-

gration of the services into the district health system and

train the PHC staff to render DISPEL services.

The evaluation findings of DISPEL were further backed

by FAIRMED intention to adopt the Lalgadh Model in

Nepal and making strategy shift from the present service

delivery model to a prevention model that is grounded

in community and empowers the PAL. To continue the

services as a sustainable, comprehensive and holistic

option, it was suggested that FAIRMED pilot an inte-

grated Prevention of Impairments and Disabilities(POID)

services in the public system of East Godavari and Gun-

tur districts. FAIRMED chose to work with the existing

partners- RISDT in East Godavari and GRETNALTES in

Guntur.

KEY POID SERVICES

Ulcer Care

Self Care Kits

MCR

Supportive Medicines

Abbreviations Background

ADMHO (A&L) Additional District Medical and Health Officer (AIDS & Leprosy)

APMO Assistant Para-Medical Officer

ANCDR Annual New Case Detection Rate

ASHA Accredited Social Health Activist

ATP Advance Tour Program

CHNC Community Health and Nutrition Cluster

DISPEL Disability Prevention and Education in Leprosy

DMHO District Medical and Health Officer

DPMO Deputy Para-Medical Officer

DPMR Disability Prevention and Medical Rehabilitation

GOPOID Government Official of POID

HIS Health Information System

MAT Mobile Action Team

MB Multi Bacillary

MCR Micro Cellular Rubber

MDT Multi Drug Therapy

NFA Nerve Function Assessment

NLEP National Leprosy Eradication Program

NRHM National Rural Health Misssion

PAL Person Affected by Leprosy

PB Pauci Bacillary

PHC Primary Health Center

POID Prevention of Impairments and Disabilities

PIP Project Implementation Plan

RCS Re-Constructive Surgery

RISDT Rural India Self Development Trust

SDP Service Delivery Point

SLO State Leprosy Officer

SPHO Senior Public Health Officer

THW Temproary Hospitalisation Ward

VMT Voluntary Muscle Testing

WHO World Health Organization

6 7

POID Approach

The POID project (2010-2013) in East Godavari

continues to provide POID services to the existing

4,500 PALs under the DISPEL program and addi-

tionally extending POID services to the new PAL

which is estimated to be 1,100 new cases per year

(as per the new cases identified in 2009). Among

these 1,100 new leprosy cases, an estimated 150

cases will develop Grade 1 disability; and 50 cases

will develop Grade 2 disabilities. The implementa-

tion approach is based on the four critical aspects of

care based on the learning from the Nepal model.

“The physical and social wellbeing of persons affected by Leprosy (PALs) is improved”

1. The Primary Health Care System in Preven-

tion of Impairment and Disabilities (POID) is

assured;

2. Self-care to prevent Disabilities and Impair-

ments is reinforced;

3. Access is provided to POID Services for im-

mobile and needy persons;

4. The Community Participation in POID is im-

proved; and

5. The development of the project is assured and

is continuously monitored and evaluated.

1. Disability Grade 0 cases among the new cas-

es remain on Grade 0;

2. Disability Grade 1 cases among the new

cases remain on grade 1 level or improve to-

wards Grade 0;

3. The number of disability Grade 2 cases

among the new cases is reduced (propor-

tion); and

4. The ulcer development among “old cases” is

reduced sustainably (proportion).

Strengthen Primary Health Care system to provide POID services to PAL

Strengthen self-care among PAL

Increase access to POID services among immobile and needy PAL

Enhance community mobilization and empowerment

FOUR CRITICAL ASPECTS OF POID

Overall Goal

Objectives

Indicators

Goal, Objectives and Measurable Indicators

DISA

BILIT

Y GR

ADES

Grade 0 - no visible deformity and no sensory loss

Grade 1 - no visible deformity

but sensory loss in hands and/or feetGrade 2 - visible

deformity

The support and guidance of Dr. Tarachand

Naidu, Addl. Director, Health and State Leprosy

Officer, Government of Andhra Pradesh, and Dr.

Pavan Kumar, Addl. DMHO, East Godavari has

resulted in firmly grounding the POID Program-

mme in the district. Dr. Pavan Kumar, personally

monitors the program on a monthly basis and

makes supportive supervisory visits to the pro-

gram area and provides the technical support to

the teams.

8 9

In East Godavari, leprosy prevalence is high. Data

(1987) suggests that the prevalence in the district is 118/

10, 000 & more than 80, 000 PALs have been cured with

MDT. At present, the district has three medical colleges,

three area hospitals, one district headquarter hospital,

ten community health centers (CHCs) and seventy one

primary health centers (PHC) to cater to the health needs

in the district. With the presence of traditional sex work-

ers, high-way network, in and out migration, the district

has a high proportion of HIV/AIDS. The forest area (un-

der the Integrated Tribal Development Authority (ITDA),

is known for high incidence of Vector Borne diseases.

The wetlands area is affected by frequent Gastro Intes-

tinal diseases

The epidemiology of leprosy in East Godavari district

under National Leprosy Eradication Program is shown in

the below graph. Cases registered for the year 2009-10

are 293, new detections ANCDR 507, Grade-1 among

new case are 6 (1.2%) and Grade -2 is 13 (2.6%). The

trend in registrations and Grade-1 and Grade-2 in new

cases has been reduced with the efforts made by field

staff and medical personal through proper treatment

services at the earliest. The decline is in new registra-

tions, from April 2009 to Mar 2012 and also Grade-1

and Grade-2 among new cases. Again we could see the

raise in new case registration during the period April-

December 2012; there are 336 new case registrations

only for 9 months which is more than previous years’

registrations. The present year prevalence rate is 0.65%

for 10000 population and percentage of Grade -1 is 1%

and Grade-2 is 2.7%.

POID Program Area – East Godavari

66 6

East Godavari Epidemiology

293

507

268

459

282

482

336

376

511

410

17

Cases registered P.R New cases detected ANCDR

Gr-1 among new cases Gr-2 among new cases

6

136

2009-10 2010-11 2011-12 Apr to Dec-12

INDEXINDEXDist. Hd.QtsMat-1. Hd.QtsMat-2. Hd.QtsCHNC

PHC

Gangavaram

Pidathamamidi

D.palem

Yellavram

Denkarai

Chavitidibbalu

Maredimilli

P.Geddada

Sitapalli

Vadapalli

Rampachodavaram

Addateegala

Zeddangi

Lagarai

Rajavommangi

*

*

*

*

*

*

*

*

*

*

*

*

*

*

Devipatnam

K.Modalu

Indukurupeta

Narasapuram

Mangampadu

Gurthedu

Boduluru

Jaggampeta

KirlampudiVeeravaram

Geddanapalli

Prathipadu

Peddipalem

RachapalliYeleswaRam

KatravulaPalli

Suravaram

Gandepalli

RangamPeta

Tuni

RavikampaduThondangi

K.P.Puram

Gollaprolu

Kandrakota

Pultmere

Kotananduru

Sankhavaram

RISDT1

Rowthulapudi

P.MallaPuram

Peddapuram(U)

Peddapuram

*

*

*

*

*

*

*

***

* * **

*

**

**

*

*

Gokavaram

Kadium

ChoppellaP.Palla

Alamuru

Thapeswaram

Mandapeta

DwarapudiK.Kuduru

R.C.Puram

Drakramam

D.Kesavaram

Ramavaram

K.Luru

Angara

Vakatippa

K.P.Puram

Anaparthy

Rayavaram

PamarruDangeru

PekeruKundura

See Thanagaram

Kotikesavaram

Rajahmundry

KoruKonda Dosakapalli

Rajanagaram

Palacharla

**

*

***

*

*2

**

* **

*

*

**

*

**

*

**

*

* * **

** Dav

ales

war

am

uru

BiccavoluVetlapalem

Samalkota

Panduru

IndraPalem

Vimuki(C)

K.K.D.Ward

KarapaSampara

Gollapalem

Thallarevu

Dugguduru

Velangi

G.MamidadaPedapudi

Peddada

U.KothapalliNagulapalli

Komaragiri

PithapuramVirava

**

*

*

*

* *

*

*

**

**

**

*

*

*

KatreniKona

UppalaGuptam

B.PalliAmalapuram

RazoleNagaram

Tatipaka

AllavaramGodilanka

B.lanka

MamidiKuduru

InavalliV.Palem

Ambajipeta

Mukmala

P.GannaVaram

Ravulapalem

KothapetaVanapalli

*

**

*

***

**

*

**

*

***

**

*

**

*

*

*Malikipuram

MoriSakhinetiapalli

Rameswaram

Lakkavaram

**

**

*

*

I.PolavaramT.Kothapalli

P.Kurru

Kesanakunu

G.V

emav

aram

Kothalanka

Serulanka

A.Puram

Ryali

Ubalmla

G.Puram

Mummidivaram

East Godavari District

West GodavariDistrict

Vizag District

Khammam District

Bay Of Bengal

Processes

Preparatory Phase - 2010

After the launch of the program in early 2010, the pro-

gram conducted a one-day workshop (February 2010)

to all NLEP vertical staff, during which time the details

of the POID program were shared. This was followed by

an eight-month period (February to October 2010) of

intensive data collection of PALs with disability. During

this time, the DISPEL records were compiled including

updation of PHC/Revenue division wise informaton. The

patient disability card was also finalised by the program.

The NLEP staff were trained (October 2012) in “how to

fill-up the POID PAL disability card”, and PHC-wise dis-

ability cards were distributed to the staff.

DM & HO provided all the support to involve all the

PHC staff members to adhere to the process of POID.

Following the training, the RIDST POID staff in collobo-

ration with the ADMHO office identified and positioned

Mobile Action Teams (MAT). Each MAT consists of a

Physiotherapist, Counselor and Driver. It was decided

to place the team at RISDT campus in Kathipudi and the

other team in Rajahmundhry. PHCs were alloted to the

MATs.

10 11

Implementation Phase – 2011-2012

Since the beginning of 2011, the MATs starting moving

to POID clinics at the Primary Health Centres and Urban

Health Centers, with each PHC/UHC covered once in

every quarter. The main activities of MATs at POID clin-

ics include:

• The Advance Tour Plan (ATP) of each MAT needs the

approaval of ADMHO, who will communicate the

ATP to the concerned SPHO/DPMO/MO/APMO

in advance. The ATP will cover 15 – 20 PHCs per

month.

• Old patients missed for registration for the POID

services are included and all services rendered to

them.

• PHC / UHC level available personnel are trained to

perform Home Self-Care and dressing.

• Home Self-Care is being supervised by ASHAs at

the village level along withthe Self Help Groups

Key tasks of MAT at PHC/Service Delivery Point

• Under the leadership of MO/GOPOID the POID ser-

vices camp is being organised in the premises of

PHC/CHNC.

• Self-care counseling session on eye, foot and hand

care is demonstrated and the same is practiced by

the patients under the supervision of the MAT.

• Physiotherapy exercises (active & passive) are

practiced by the PALs and guided by the MAT.

• Patients are trained on how to dress the wounds

by themselves under the guidance of the MAT.

• Appliances like protective footwear (MCR), dynamic

splints, self care kits are issued by the MATs.

• Patients in need of medication and dressings are

examined and the same is being provided by the

Medical Officers of the PHC.

• Documentation i.e. preparation and updat-

ing the PAL disability cards, if pending.

• Nerve Function Assessment (NFA) for new cases that

are detected during 2009-10 & 2010-11 and in the

current year and preparation of relevant records.

• Immobile patients i.e. patients in need of hospi-

tal services are referred by the Medical Officer

through referral slips.

• Identification and selection of RCS cases among

the PALs attending the camps.

• Sensitization on POID to PHC staff during staff

meetings.

• Contacting and involving Village Health & Sanita-

tion Committees (VHSC).

• Collection of information on welfare activities of

government and inform the same to the DLO for

further action.

12 13

Results

• Progress of theProgram - 2012:During the re-

porting period (January to December 2012), the

POID program in East Godavari has been able to

train over 10,000 PAL in self-care. As the program

provides self-care kits to only the needy patients,

4,035 PAL were provided kits during this period.

Nearly half (4,915) of the patients trained in self-care

underwent physio-therapy sessions at the RISDT

center in Kathipudi. MCR footwear was provided to

2,728 PAL. During this period, 1,168 patients were

admitted in the hospital and 358 visited the Primary

Health Centers.

• DisabilityStatusofPAL: During

the period, 2010-2012 the status

among the PAL varied both in

Grade 1 and Grade 2 disabilities.

The average percentage among

Grade 1 has been around one

percent over the last three years.

During the same period, the per-

centage among Grade 2 disabili-

ties has been around 2%.

Disability Status (2010-2012)

2009-10 2010-11 2011-12 Apr 2012-Dec 12

New detections 507 459 482 376

Grade-1Disability 6 (1.2%) 1 (0.21%) 5 (1.3%) 4 (1%)

Grade-2 Disability 13 (2.6%) 7 (1.5%) 11 (2.3%) 10 (2.7%)

Disability Cases - Dec 2012

Gr- 2 Disability 4008

Gr- 1 Disability 399

POID Progress: Jan-Dec 1210,009

Trained in self care

Self Care KitsProvided

Admitted in Hospitals(referred from PCHs)

Underwent Physio Therapy services

Visited PHCsProvided MCRChappals

2,728

4,035

1,168

4,915

358

• MassContact:Based on the feedback from the re-

view meetings,“Mass Contact“program has been

organised by MATs to improve clinic attendance

rate under the supervision of District Nucleus in

2011 and 2012.

• Eye Care: On the recommendations of the pro-

gram advisors, screening of all PAL with disabilities

for defective vision and cataracts is being under-

taken, utilizing the services of existing ophthalmic

assistant officers at CHNCs / PHCs.

• CommunityBasedRehabilitation:Since CBR is an

integral part of POID FAIRMED arranged a consul-

tant who visited (August 2011) POID clinics and ad-

vised on ways and means to strength in CBR activi-

ties. During the year, RISDT team linked over 4,000

PAL to various social security schemes available in

the government system. 2,073 PAL have recieved

Antodaya Cards, making their households food se-

cured. 1,608 PAL have started receiving Rs. 500 per

month disability pension and 1,422 became eligible

for Rs.200 per month pension.

• InpatientCare:A 65-bedded in-patient ward is managed at RISDT-Kathipudi and 10-bedded THW ward is avail-

able at GGH-Kakinada.

• ProvisionofSelf-CareKitstoPALwithUl-

cers:Self-care kits were provided to needy

ulcer patients, after a formal training on

self care of ulcers helping them to manage

or care for their ulcers. All PALs with ulcers

were not provided with self-care kits but the

needy patients were provided with number

of times. The number of affected PAL pro-

vided with self-care kits is more than the

number of ulcer patients registered with the

organisation. In the year 2010-11, 1,624 ul-

cer cases were treated and 1,625 self care

kits were provided to the needy patients at

different points of time. Higher number of

self-care kits were provided in the year 2011-

12, which is 4,573 kits. A total of 8,801 kits

were provided to needy patients during the

period April 2010 to December 2012.

CBR Progress: 2012

Total disability cases 4,407

PALsreceived AAY2,073

PALsgetting 200 pension1,422

PALsgetting 500 pension1,608

Ulcer patients provided with self care kits

2010-11

1,624 1,625 1,719

4,573

1,722

2,603

Total ulcer patients Self care kits provided

2011-12 Apr-Dec-12

14 15

• Re-Constructive Surgeries:RCS center at RISDT-

Kathipudi with 20-beds is acenter recognized by the

Government of India (GOI) for conducting RCS op-

erations. So far 716 surgeries have been conducted

with PAL from seven districts availing the services.

• CommunityParticipation:Village Health and Sani-

tation Committees at village-level are roped in to

the POID program. AHSAs participation in guiding

self-help groups is a key activity. Local service or-

ganizations like Lions Club, Satya Sai Organization,

Arya Vysya Sangam, Mano Vikasa Kendram have

also participated in the POID projects and provide

various services like food items, besides provision of

eye sight glasses, clothing, artificial limbs, tricycles,

etc.

• MATs will transfer all cards to the GOPOID (PHC)

during the first six months of 2013 and entrust the

conduct of POID clinics to GOPOIDs at PHC month-

ly once and sub-center level weekly once i.e. on

Wednesday and provide daily supervision support

to ASHAs for the Home Self-Care activity at village

level.

• If there are any untrained GOPOIDs, they will be

trained.

• MATs will guide and supervise the conduct of POID

clinics at PHC level by GOPOIDS and sub-center

level by the ANMs and assist them preparation of

the relevant reports during second half of 2013.

District 2007 2008 2009 2010 2011 2012 Total

East Godavari 36 23 35 26 74 60 254

West Godavari 5 26 15 1 1 1 49

Visakhapatnam 39 51 28 19 14 13 164

Warangal 29 30 17 1 18 29 124

Karimnagar 15 55 38 0 10 4 122

Krishna - - - - 0 1 1

Srikakulam - - - - 0 2 2

TOTAL 124 185 133 47 117 110 716

Maintenance Phase – 2013

Capacity Building

During the implementation period, the RISDT POID

team built the capacities of various NLEP and PHC func-

tionaries. The details of these training programs include:

• One-day orientation for GOPOIDs in three batches

in December, 2010;

• Medical Officers in two batches in December, 2010;

• For supervisory staff in December, 2010;

• Positioning and placement of two MATs and trained

along with supervisory staff;

• Procurement and logistics training .

• Dressers @ 1 per colony i.e. from ‘17’ leprosy colo-

nies available in the district were trained in January

2011.

As follow-up action and on the recommendation of Dr.

Krishnan and Dr. Akshay to strength the Nerve Function

activity, one-day training program was organised for

MOs, GOPOIDs,

NLEPstaffandASHAcoordinators:

• 23 January 2012– One batch of NLEP staff

• 25-26 January 2012- Two batches of Medical

Officers

• 3-4 February 2012- Six batches of GOP

OIDs & ASHA

SupportiveSupervisionandMonitoring

• Dr.TV Venkateswaralu, retired State Leprosy Offi-

cer advisesthe POID project and provides support-

ive supervision to the MATs at POID clinics, every

month for six-days a month and also attends the

monthly review meetings.

• Dr. Anand Krishnan, senior Leprologist is the

FAIRMED advisor for POID and provides backstop-

ping support once every quarter and guides the

POID program as per the standard operating pro-

cedures.

• SPHOs at CHNCs and MOs at PHCs will supervise

the POID activity during the monthly review meet-

ings.

• District POID steering committee chaired by District

Collector reviews the program once in a quarter.

• State Leprosy Officer and Additional Director, Lep-

rosy also made a supervisory visit to the POID proj-

ect in March, 2012.

• Dr. Akshay, National Technical Coordinator –

FAIRMED and NLEP consultant of Central Leprosy

Division madevisits to the program.

16 17

POID Organograms

A. POID Project Structure

B. POID District Steering Committee

C. RISDT POID Staff Organogram

POID in news

FAIRMED India Office Mumbai

Co-ordinator (Hyderabad)

Andhra Pradesh State Leprosy Unit

RISDT Rajahmundry & GRETNALTES Tenali

Andhra Pradesh District Leprosy Units

Primary Health centres in the districts

Referral and Training Centres of Partnet NGOs of Fairmed

PALs

Self care groups

Counsellig and socio development cell

Chaiperson - District Collector

Vice ChairmanDM&HO

MemberRISDT

Representative

MemberDist. Social

Welfare Officer

MemberDist. Asst.

Director (PH)

Member DRDA Officer

Member DIstrict Tribal

Officer

Secretary ADM&HO

Vice Chairman FAIRMED

Representative

Project Co-ordinator

Medical Superintendent

Administrative Staff

Counselor

Physiotherapist

Driver

Community Volunteer

18 19

Annexures

20 21

22 23

24

RURAL INDIA

SELF DEVELOPMENT

TRUST

Rural India Self Development Trust

Post Box No. 56, 90-1-5/1, Swaraj Nagar, Alcot Gardens, Rajahmundry

533 101, E.G.Dt. Andhra Pradesh, India. Phone: +91 883 242 53 67.

Referral Hospital (Community Health Center) (Rural India Self Development Trust)

Seetayammapeta, Sankavaram Mandalam, E.G.Dt.

Andhra Pradesh India. Phone: +91 8868 234 408.

Referral English Medium High School (Rural India Self Development Trust)

Tammayyapeta, Thondangi Mandalam, E.G. Dt.

Andhra Pradesh, India. Phone: +91-8868 234 810

risdtindia@gmail.com

www.risdt.org

www.kalpavruksha.ch (German)

Rural India Self Development TrustRajahmundry, Andhra Pradesh