SL hospitals must improve facilities for patients with disabilities: Study

• Study on the provision of services to leprosy patients notes lack of accessibility
  No WP hospital had toilets for leprosy patients with disabilities – Study
  Elevators to clinics, corridors with wheelchair access, toilets essential 

By Ruwan Laknath Jayakody 

Hospitals in the country should improve access to facilities for patients with disabilities including having an elevator to clinics, corridors with wheelchair access, and toilets, a recent study on the provision of health care services to leprosy patients in the Western Province found.

This finding was made in an original research titled “Health care service provision to leprosy patients in the Western Province” authored by N. Liyanage (attached to the National Programme for Tuberculosis Control and Chest Disease), S.M. Arnold (the Health Ministry’s Quarantine Unit’s Director), M.S.D. Wijesinghe (attached to the Health Promotion Bureau) and D.M. Amarathunga (attached to the Gampaha District General Hospital [GH]) which was published on 9 July 2021 in the Journal of the College of Community Physicians of Sri Lanka 27th Volume’s First Issue. 

According to the Anti Leprosy Campaign, roughly 2,000 cases are reported per annum with the majority from the Western Province, also owing to contact tracing. Owing to leprosy’s association with chronic morbidities such as vision impairment, limb disability, wounds, and complications related to nerves, patients require rehabilitation. 

This is done through management with multi-drug therapy (MDT) at dermatology clinics (DC) conducted in base hospitals (BH) under the purview of consultant dermatologists. Additionally, community health staff in the field and those at the offices of the medical officer of health (MOH), provide health education to family members.

Health service provision is defined by the World Health Organisation (WHO) as “the way inputs such as money, staff, equipment, and drugs are combined to allow the delivery of a series of interventions or health actions” and lists adequate financial support, skilled health care staff, adequate facilities and equipment, the secured provision of essential drugs and supplies, up-to-date evidence-based clinical guidelines and appropriate operational policies as key inputs for the delivery of healthcare. 

As explained by G.S. Cameron and R.S. Martin in “The challenges of service provision”, expanding access, coverage, and the quality of health services depend on the available resources, the arrangement of the services and the way it is managed, and on having adequate incentives to encourage health workers and patients.

Liyanage et al., pointed out that the lack of training for field health workers on leprosy screening, inadequate human resources, and work overload result in poor field services in managing such.

Therefore, Liyanage et al., conducted a descriptive cross-sectional study in 2018 in leprosy clinics (LC), DCs, MOH offices, routine clinics in teaching hospitals (THs), GHs, BHs, and special satellite clinics in the Western Province (Colombo, Gampaha, and Kalutara Districts).

The clinic service provision checklist included the assessment of the infrastructure, the basic facilities, the services available to patients, equipment, human resources, the availability of drugs, and patient referrals. Healthcare service provision in leprosy clinics is measured through accessibility and access, infrastructure (ventilation, power supply, lighting, equipment, and stationary), registration (appointment system, seating, and waiting facilities), cleanliness, laundry and waste management, sanitary facilities for patients and staff (toilets, drinking water, hand washing), health education and counselling, clinic processes (lab services and issuing drugs), and human resources (availability and training programmes). 

With regard to accessibility and directional signs to leprosy clinics, the factors considered included the nature of the clinic building (whether the building is a permanent one), easily reachable, vehicle access, disability access, wheelchairs and trolleys, working lift, entrance, directional signs, name boards in all three languages, visibility, rooms with signs and toilets with signs.

Some leprosy service facilities such as blood investigation facilities, diagnostic facilities (skin biopsy and slit skin smear [SSS] test), issuing MDT drugs, the availability of physiotherapy facilities are not available in divisional hospitals (DHs) when compared to BHs.

The checklist on the assessment of healthcare service provision to leprosy patients in a MOH office consists of the availability of maps, charts, relevant registers and records, human resources, attributed related to disease notification, the status of contact tracing, and health education on notified leprosy cases in the area.

A model leprosy clinic is the only clinic that is designed to provide services exclusively for leprosy patients, as all other clinics provide services for leprosy as well as other dermatological conditions. Data were collected from all 12 DCs, pharmacies, laboratories, and physiotherapy units in the above hospitals.

In terms of the deficiencies in service provision that were identified, it was found that: five out of the 12 DCs were situated upstairs; two hospital clinics did not have a working lift for patients (in some cases, the leprosy clinic is conducted in the ground floor as well as upstairs and the upstairs building does not have a working lift); half of the hospitals did not have directional signs and properly visible name boards to help locate the clinic; a majority did not have trilingual name boards; a model leprosy clinic in a TH in the Colombo District, had inadequate infrastructure facilities in terms of the clinic space and the waiting areas; at a model leprosy clinic in a GH in Gampaha, the waiting area had poor ventilation and was in a corridor, which was blocked during clinic time; the appointment system was not implemented (the appointment book was not maintained at THs and BHs) except in a model leprosy clinic at a TH in Gampaha and a BH in Kalutara, as the other hospitals gave only a next clinic date but not the time, which in turn meant that all patients had to wait for a long time to get the treatment.

It was also noted that the clinic leprosy (CL) register was not available in all DHs except in one, and even that was not updated owing to patient diagnosis not being carried out at the said centre; there was inadequate space found in the clinic premises for medical officers (thereby guaranteeing privacy during consultation) in certain THs, a GH, and BHs, while adequate space was found in one GH in Kalutara and all DHs; no hospital had toilets for patients with disabilities.

Other findings were that a separate place for patient counselling was available at a model clinic, a TH, and a DH; leprosy-related health education material was available in all hospitals; most DHs did not have a laboratory with the ones that did being equipped with poor facilities; in a DH in Colombo, a laboratory facility was not available, and the blood samples that were collected were sent to the nearest BH for analysis which resulted in the patients having to wait for a day to obtain the reports; the full blood count (FBC) was the only blood test carried out in the DH in Gampaha and although facilities were available for liver function tests and serum creatinine, there was only one medical laboratory technician (MLT) available and therefore they were not performed.

Additionally, it noted that the facility to ascertain whether the patient had G6PD deficiency (a blood investigation) was only available at two clinics in Colombo and one clinic in Kalutara; the SSS and skin biopsy facilities were not available in one BH in Colombo which sent the samples to another BH; MDT was not issued in the DHs due to the unavailability of proper laboratory facilities; MDT and three drugs used to manage leprosy related reactions were not available in the DHs; a separate pharmacy counter was allocated for the clinics at a model clinic, two THs, and two GHs; the pharmacies were not air-conditioned in a BH in Gampaha and all three DHs; micro-cellular rubber (MCR) shoes and splints (gutter and forearm splints) were not available in a GH in Gampaha and a BH in Colombo; there is a physiotherapy unit at a DH in Colombo, but it was not functioning due to the non availability of a physiotherapist; and wound care and contact screening facilities were available in all the hospitals.

The highest percentage of scores was achieved by a model clinic and GH in Kalutara, while the lowest score was from the BH in Kalutara. The scores of all the hospitals were above 75%, indicating an overall satisfactory service provision in all clinics of all categories of hospitals including the DHs in the Province.

As per the selected MOH areas in the Province, in 2017, the highest number of cases in Colombo were found in the Colombo MOH Areas One (88 – 27.5%) (also, despite reporting the highest number of cases in a single Public Health Inspector [PHI] area, health education and contact screening was less than 50%), Two (38), and Three (14), while untraceable cases were high in the Colombo MOH Area Two (10), which amounted to approximately 20% of the total cases. In the Colombo MOH Areas Five and Seven, all cases were investigated within the first seven days.

In Gampaha, the highest number of cases was found in the Gampaha MOH One (31), Two (13), and Three (12) Areas. Leprosy was however not included in the relevant maps and charts. The Gampaha MOH Area Three showed the highest percentage (92%) of case investigations carried out within the first seven days. Case investigation after 14 days was 61% in the Gampaha MOH Two and 60% in the Gampaha MOH Four.

In Kalutara, the MOH Areas One (43), Two (25), and Three (6) had the highest number of cases.

Health education and contact tracing were 100% in the Colombo MOH Areas Four and Seven, MOHs Four and Seven in Gampaha, and MOHs Four, Five, and Six Areas in Kalutara.

Regarding the screening of leprosy contacts at MOH offices, in the Colombo MOH Area Two, Gampaha MOH Areas One, Four, and Seven, and Kalutara MOH Three was carried out on all working days. In the Colombo MOH Areas One, Five, Six, and Seven, Gampaha MOH Two and Kalutara MOH Areas One, Four, Five, Six, and Seven, contact screening was carried out for households once a week. In the Kalutara MOH Area Two, it was carried out once a month.

None of the MOH offices displayed a notice, stating that leprosy contact screening was carried out at the MOH office.

Considering the maintenance of the registers and records of the 22 MOH offices surveyed, most (15 – 68.2%) of the areas satisfactorily maintained their records. However, seven MOH areas had poor record keeping. The maintenance of records was very poor in Gampaha. In certain cases, the investigated dates are not mentioned in the Notification and Identification Infectious Diseases (ID) Register. In others, the Leprosy Register was not updated. 

There was also a discrepancy between the number of confirmed cases recorded in the Notification Registers (NR) and the ID Registers. Data was not compatible between the NR and ID registers. Dates of investigation were not recorded. Some columns were not updated. In the ID Registers, the dates of investigation and all the confirmed cases were not recorded. As far as the leprosy contact (LC) Register was concerned, this was not maintained for 2017. The NR register was incomplete. 

Data entering started since 7 October 2017 due to the unavailability of a supervising PHI. Patients’ names in the ID Register and LC Register were incompatible. There were discrepancies in the case investigation dates in the NR and ID Registers. The LC Register was not maintained in 2017. The NR and ID Registers were entered in a single Register in 2017. The LC Register was not maintained in 2017. The LC Register was not updated.

Since all 12 hospitals scored an aggregate of over 75 for the service provision checklist, despite certain lacunas and shortcomings, the overall service provision for leprosy patients who attended the clinics in the Province was satisfactory. As has been noted by A. Tiwari, P. Suryawanshi, A. Raikwar, M. Arif, and J.H. Richardus in “Household expenditure on leprosy outpatient services in the Indian health system: A comparative study”, having national level funding as opposed to regional funding mechanisms, improves facilities in many centres.

Explaining further, Liyanage et al., emphasised that since leprosy is a disabling condition, clinics should have proper access for disabled patients, and in this regard, if a clinic is situated on upper floors, there should be an elevator facility while the hospital management should also provide directional signs and name boards. Having an appointment system, and thereby issuing an appointment number and the time for the next clinic visit, reduces overcrowding, as well as patient waiting time, Liyanage et al., noted. Most importantly, Liyanage et al., highlighted the complete lack of toilet facilities available for disabled patients in all the hospitals despite such being a Government requirement, which is a lacuna that, they explained, must be addressed by the respective hospital administration.

Although there is a large number of leprosy patients living in the Colombo MOH Area One, its DH does not have laboratory facilities to diagnose leprosy and as a result, patients have to travel to the nearest TH or BH to get treatment. Regarding this issue, Liyanage et al., observed that establishing basic laboratory facilities at leprosy treatment centres is very important, as it is vital that leprosy treatment be commenced as early as possible in order to prevent poor patient compliance, as noted in L. Renita, S.A. Pulimood, E.P. Eapen, J. Muliyil and K.R. John’s “Health care utilisation in Indian leprosy patients in the era of elimination”.

Field investigations of notified cases should be carried out within 14 days of notification, as the incubation period of leprosy ranges from a few weeks to 30 years, and since there may be family contacts having leprosy without their knowledge. Pertaining to this, it was found that the majority of PHI areas in the Colombo MOH Area One, where case investigation was poor, included PHIs’ working under the relevant Local Government (LG) authority. 

“Since the MOH does not have direct administrative authority over these PHIs, the majority do not carry out field activities related to leprosy in a satisfactory manner due to many reasons; whereas in MOH areas where there is no LG control, the PHIs have performed well with 100% case investigations, 100% contact tracing, and health education,” Liyanage et al., added.

Although the majority of preventive activities carried out in MOH offices were satisfactory, many needed proper supervision. In this regard, it has been found that the supervision of higher officers is effective in many field based leprosy control activities (T. Muthuvel, S. Govindarajulu, P. Isaakidis, H.D. Shewade, V. Rokade, R. Singh, and S. Kamble’s “‘I wasted three years thinking it is not a problem’: patient and health system delays in the diagnosis of leprosy in India: a mixed method study”, H. Kabir and S. Hossain’s “Knowledge on leprosy and its management among primary health care providers in two districts in Bangladesh”, and D. Musoke, P. Boynton, C. Butler and M.B. Musoke’s “Health seeking behaviour and challenges in utilising health facilities in the Wakiso District, Uganda”).

Since MOHs and their staff working in the preventive health sector get less exposure to leprosy patients, the public health staff should be regularly exposed to in service trainings and awareness programmes on leprosy prevention and management, but this is not practically taking place in the majority of MOH offices, Liyanage et al., elaborated, noting in turn that the lack of knowledge and skills will result in a delay in the diagnosis of leprosy.

Of the surveyed 22 MOH offices, seven had poor record keeping, where it was noted that it took a long time to carry out case investigations, while there was low contact tracing and the non-provision of health education for leprosy affected families. Liyanage et al., therefore recommended that the clinics in the TH and Divisional GH in Gampaha be shifted to a place with adequate clinic space and waiting area, while an appointment system should be introduced to hospitals with overcrowded clinics, dedicating a specific date and time (for example, Saturday morning) for contact screening in all MOH offices, and informing of the service to the community through the mass media, and billboards displayed at MOH offices and hospitals.

Liyanage et al., concluded that since leprosy is a communicable disease, treating patients is of equal importance as preventing the spread of the disease.