Leprosy control strategies and the integration
of health services: an international perspective
Estraté g ias p ara o c o ntro le d a hanse níase
e inte g raç ão d o s se rviç o s d e saúd e :
uma p e rsp e c tiva inte rnac io nal
1 Lep rosy Un it, D ep a rt m en t of H ea lt h , Roya l T rop ica l In st it u t e, PO Box 95001, 1090 H A Am st erd a m , T h e N et h erla n d s. j.v issch ed ijk @k it .n l p .lev er@k it .n l p .feen st ra @k it .n l 2 Secret aria d e Est ad o d e Sa ú d e d e M i n a s Gera i s. Av . Afon so Pen a 2300, Belo H ori z on t e, M G 30130- 007, Bra sil. Ja n Vi ssch ed i jk 1
An ri k En gelh a rd 1
Pet er Lev er 1
M a ri a Ap a reci d a d e Fa ri a Gro ssi 2
Pi et er Feen st ra 1
Abstract In t egra t i on of lep rosy serv i ces i n t o t h e gen era l h ea lt h serv i ces i s rega rd ed a s t h e core st ra t egy t o en su re t h a t lep ro sy co n t ro l rem a i n s co st ef f ect i v e a n d eq u i t a b le, a n d , t h u s, su st a i n a b le in t h e com in g yea rs. In t h is a rt icle a n ex t en siv e rev iew is p resen t ed of t h e in t egra t ion of lep -ro sy serv i ces i n t o t h e gen era l h ea lt h serv i ces. Af t er t h e ra t i o n a le o f i n t egra t i o n i s d i scu ssed , t h e a rt i cle h i gh li gh t s sev era l recen t d ev elo p m en t s w i t h i n lep ro sy co n t ro l a n d t h e h ea lt h sect o r t h a t a re in su p p ort of t h e in t egra t ion p rocess. An ov erv iew is p resen t ed of recen t ex p erien ces in cou n -t ri es -t h a -t h a v e a lrea d y em b a rk ed on -t h e i n -t egra -t i on p rocess. Ba sed on -t h ese ex p eri en ces i m p or-t a n or-t l esso n s ca n b e l ea rn ed a n d i n co rp o ra or-t ed i n or-t o a m o d el f o r or-t h e p ro cess o f i n or-t egra or-t i o n . T h i s m od el, w h i ch i s p resen t ed a t t h e en d of t h e a rt i cle, w i ll a ssi st cou n t ri es t o su ccessfu lly i n t egra t e lep rosy serv ices in t o t h e gen era l h ea lt h serv ices.
Key words Lep rosy; H ea lt h Serv ices; St ra t egies
Resumo O a rt i go a p resen t a a i n t egra çã o en t re o s serv i ço s d e h a n sen í a se e o s serv i ço s gera i s d e sa ú d e co m o a est ra t égi a cen t ra l p a ra ga ra n t i r q u e o co n t ro l e d a h a n sen í a se p erm a n eça cu st o -ef i ca z e eq ü i t a t i v o e, co m o co n seq ü ên ci a , su st en t á v el a o l o n go d o s p ró x i m o s a n o s. O s a u t o res a p resen t a m u m a rev i sã o ex t en sa so b re a i n t egra çã o d o s serv i ço s d e h a n sen í a se co m o s serv i ço s gera is d e sa ú d e. Ap ós u m a d iscu ssã o sob re a ju st ifica t iv a p ela in t egra çã o, o a rt igo d est a ca d iv er-sa s i n o v a çõ es recen t es n o co n t ro le d a h a n sen í a se e n o set o r d a er-sa ú d e q u e a ju d a m a su st en t a r o p rocesso d e i n t egra çã o. Os a u t ores a p resen t a m u m p a n ora m a sob re a s ex p eri ên ci a s recen t es em p a íses q u e já in icia ra m o p rocesso d e in t egra çã o. Com b a se n essa s ex p eriên cia s, lições im p ort a n -t es p od em ser a p ren d id a s e in corp ora d a s a u m m od elo p a ra o p rocesso d e in -t egra çã o. T a l m od e-lo, q u e é a p resen t a d o n o fin a l d o a rt igo, irá a u x ilia r os d iv ersos p a íses n a in t egra çã o d os serv iços d e h a n sen ía se com os serv iços gera is d e sa ú d e.
Introduction
Ove r t h e p a s t d e c a d e s t h e n u m b e r o f n e w le p -ro sy p a tie n ts d e te cte d wo rld wid e h a s b e e n m o re o r le s s s t a b le (WH O, 2002). In 2001 m o r e t h a n 750,000 n e w p a t ie n t s w e r e d ia gn o s e d (WH O, 2002). It is ve r y like ly t h a t a sign ifica n t n u m b e r o f n e w p a t ie n t s will co n t in u e t o o ccu r fo r m a n y ye a r s. H e n c e , le p r o sy c o n t r o l a c t ivit ie s sh o u ld b e su st a in e d , a n d t o gu a ra n t e e su st a in a b le le p -r o s y s e -r vic e s t h e y s h o u ld b e in t e g-r a t e d w it h in th e ge n e ra l h e a lth se rvice s (ILA, 2002).
Th e ch a n ge fr o m a ve r t ica l t o a n in t e gr a t e d p ro gra m is fa r fro m e a sy a n d ca n n o t b e a cco m -p lis h e d o ve r n igh t (So u t a r , 2002). Ex-p e r ie n c e s wit h in t e gr a t io n p r o ce sse s in se ve r a l co u n t r ie s re ve a l t h a t su cce ssfu l in t e gra t io n re q u ire s go o d p r e p a r a t io n a n d p la n n in g, a n d t h e a d d r e s s in g o f se ve ra l h u rd le s, m a n y o f t h e m sp e cific t o t h e lo c a l c o n t e xt . In t h is a r t ic le w e w ill r e vie w t h e d e fin it io n a n d r a t io n a le o f in t e gr a t io n a n d will a sse ss re ce n t e xp e rie n ce s, b o t h in Bra zil a s we ll a s o t h e r c o u n t r ie s . We w ill h igh ligh t s e ve r a l c u r r e n t d e ve lo p m e n t s t h a t fa c ilit a t e t h e in t e -gr a t io n o f le p r o sy c o n t r o l. Ba se d o n t h e a n a ly-sis o f re ce n t e xp e rie n ce s we will in d ica t e wh ich le sso n s ca n b e le a rn e d a n d , fin a lly, we will p re se n t a st e p b yst e p m o d e l fo r t h e p ro ce ss o f in -t e gra -t io n o f le p ro sy co n -t ro l.
Sources and search methodology
In o r d e r t o r e vie w a ll a va ila b le lit e r a t u r e , w e ca rrie d o u t a se a rch in MEDLINE fo r t h e p e rio d 1985 t o 2003, u sin g t h e ke y wo rd s “le p ro sy” a n d “in t e gr a t io n ”. Th e s e a r c h yie ld e d o ve r 50 a r t ic le s . Th e d o ic u m e n t s w e r e a s s e s s e d b y t h e a u -t h o rs a n d in co rp o ra -t e d in so fa r a s -t h e y we re fe l-t r e le va n t fo r t h e r e vie w . In a d d it io n , o t h e r r e -s o u r c e -s -s u c h a -s t h e In t e r n a t io n a l Le p r o -s y A-s- As-s o c ia t io n (ILA)- Te c h n ic a l Fo r u m Re p o r t (ILA/ TF, 2002) a n d d is c u s s io n s a n d p r e s e n t a t io n s d u r in g t h e r e c e n t 16t h In t e r n a t io n a l Le p r o s y Co n gr e ss in Sa lva d o r , Br a zil (ILA, 2002b ), c o n -t rib u -t e d -t o -t h is re vie w. Th e a u -t h o rs’ e xp e rie n ce a s co n su lt a n t s t o le p ro sy co n t ro l p ro gra m s wa s a lso u t ilize d fo r t h is a rt icle .
Definition and rationale
of integration of leprosy services
In t e gr a t io n h a s b e e n d e fin e d in d iffe r e n t wa ys, va r yin g fr o m t h e c o lla b o r a t io n wit h o t h e r p r o -gr a m s t o t h e fu ll a b so r p t io n o f le p r o sy se r vice s in t o n a t io n a l h e a lt h s ys t e m s , w it h o u t le a vin g a n y r o o m fo r le p r o s y s p e c ific e le m e n t s . Co n
-s e n -s u -s n o w e xi-s t -s t h a t in t e gr a t io n o f le p r o -s y s e r vic e s w it h in t h e ge n e r a l h e a lt h s e r vic e s m e a n s t h a t le p r o s y c o n t r o l a c t ivit ie s b e c o m e t h e r e s p o n s ib ilit y o f t h e ge n e r a l h e a lt h s e r -vice s, i.e ., in vo lvin g m u lt ip u rp o se , co n t in u o u s, a n d co m p re h e n sive se rvice s wh ich a re a s clo se t o t h e co m m u n it y a s p o ssib le (Fe e n st r a , 1993). In t e gra t io n d o e s n o t im p ly t h a t sp e cia lize d e le -m e n t s a r e u n n e c e s s a r y. O n t h e c o n t r a r y, t o a ce rt a in e xt e n t sp e cia liza t io n is n e e d e d fo r p o li-c ym a kin g, t r a in in g, s u p e r vis io n , a n d r e fe r r a l. So m e o f t h e se t a sks n e e d t o b e p e r fo r m e d b y a ce n t ra l u n it in t h e Min ist ry o f H e a lt h , o t h e rs a t t h e in t e r m e d ia t e (r e gio n a l/ p r o vin c ia l) le ve l. D u rin g t h e 16t hIn t e rn a t io n a l Le p ro sy Co n gre ss in Sa lva d o r , Br a zil, t h e c o n s e n s u s a b o u t in t e -gr a t io n w a s c o n fir m e d b y a n ILA r e s o lu t io n (ILA/ TF, 2002).
An im p o r t a n t a r gu m e n t fo r t h e in t e gr a t io n o f le p r o s y c o n t r o l is t o e n h a n c e t h e s u s t a in a b ilit y o f le p r o s y s e r vic e s (ILA/ TF, 2002). Be c a u s e t h e d u r a t io n o f t r e a t m e n t h a s b e e n r e -d u c e -d s u b s t a n t ia lly o ve r t h e p a s t ye a r s , t h e wo rklo a d fo r t re a t in g a n d fo llo win g u p p a t ie n t s h a s d e cr e a se d a cco r d in gly. H e n ce , su ch a ct ivi-t ie s a r e le s s c o s ivi-t - e ffe c ivi-t ive , p a r ivi-t ic u la r ly w h e n ve rt ica l le p ro sy wo rke rs h a ve t o t ra ve l lo n g d ist a n c e s fo r r e la ist ive ly fe w p a ist ie n ist s . Ve r ist ic a l s e r -vic e s h a ve b e c o m e e xp e n s ive a n d c a n u s u a lly o n ly b e m a in t a in e d w it h c o n s id e r a b le d o n o r s u p p o r t . M o r e o ve r , in a r e a s w h e r e p r e va le n c e is d e clin in g, in t e gr a t io n will h e lp in su st a in in g t h e M u lt i- D r u g Th e r a p y (M D T) se r vic e s (N e ir a & D a u m e rie , 2000).
In t e gr a t io n e n h a n c e s t h e a c c e s s ib ilit y a n d eq u ity o f services (Feen stra & Vissch ed ijk, 2002). Th e Wo r ld H e a lt h Or ga n iza t io n (WH O) Exp e r t Co m m it t e e o n le p r o s y e m p h a s iz e d in it s s e ve n t h r ve p o r t t h a t in t ve gr a t io n c o u ld im p r o vve lo -c a l -c o m m u n it y a w a r e n e s s , -c a s e fin d in g, a n d p a t ie n t s ’ a c c e s s ib ilit y t o M D T, a n d c o u ld h e lp t o e n s u r e t h e r e gu la r it y o f t r e a t m e n t (WH O , 1998). It in d ic a t e s t h a t fu lly in t e gr a t e d p r o -gr a m s m a y b e m o r e e ffe c t ive in s t r e n gt h e n in g le p ro sy e lim in a t io n a ct ivit ie s t h a n ve rt ica l p ro -gr a m s . Fu r t h e r m o r e , ve r t ic a l s e r vic e s o ft e n se r ve t o m a in t a in t h e st igm a t h a t is u su a lly a t-t a c h e d t-t o le p r o s y (Ar o le e t-t a l., 2002). Th r o u gh in t e gra t io n , le p ro sy b e co m e s a n “o rd in a ry” d is-e a s is-e , w h ic h d o is-e s n o t w a r r a n t s p is-e c ia l s is-e r vic is-e s a n d a p p ro a ch e s.
Recent developments facilitating
integration of leprosy control
in t e gra t io n o f le p ro sy co n t ro l, t h is is re in fo rce d b y s e ve r a l r e c e n t d e ve lo p m e n t s , b o t h w it h in a n d o u t sid e le p ro sy co n t ro l p ro gra m s (Fe e n st ra & Vissch e d ijk, 2002):
• Wh ile t h e n u m b e r o f n e w ly d e t e c t e d c a s e s is m o re o r le ss st a b le , t h e re gist e re d p re va le n ce o f le p r o sy h a s b e e n r e d u ce d su b st a n t ia lly (Fig-u re 1). Th is is m a in ly th e res(Fig-u lt o f th e sh o rten in g o f t h e t r e a t m e n t d u r a t io n a n d t h e u p d a t in g o f re gist e rs (Vissch e d ijk e t a l., 2000). Flu ct u a t io n s in c a s e d e t e c t io n r a t e s in a fe w c o u n t r ie s h a ve m o s t ly b e e n c a u s e d b y o p e r a t io n a l a s p e c t s s u c h a s t h e im p le m e n t a t io n o f Le p r o s y Elim in a t io in Ca m p a igin s (LECs ) (WH O , 2000a ). U in -fo r t u n a t e ly, go o d in -fo r m a t io n a b o u t t h e r e a l in cid e n ce is n o t a va ila b le (Sm it h , 1997). So fa r, it is u n like ly t h a t MDT, wh ich h a s b e e n re co m m e n d e d a s t h e p r e fe r e n t ia l t r e a t m e n t fo r le p -r o s y s in c e 1981 (WH O, 1982), h a s -r e d u c e d t h e t r a n s m is s io n o f le p r o s y a s c o m p a r e d t o t h e p r e vio u s ly u s e d d a p s o n e m o n o t h e r a p y (ILA/ TF, 2002). Th e r e fo r e , s ign ific a n t n u m b e r s o f n e w c a s e s o f le p r o s y w ill c o n t in u e t o o c c u r , m a n y o f t h e m a lr e a d y wit h d isa b ilit ie s. Ot h e r s m a y e ve n d e ve lo p d is a b ilit ie s a ft e r d ia gn o s is . H e n c e , d e s p it e t h e r e d u c e d p r e va le n c e , c o s t -e ff-e ct iv-e a n d a cc-e ssib l-e l-e p r o sy s-e r vic-e s (d ia g-n o s is , t r e a t m e g-n t , p r e ve g-n t io g-n o f d is a b ilit ie s , d is a b ilit y c a r e , r e h a b ilit a t io n ) h a ve t o b e s u s-t a in e d fo r d e c a d e s s-t o c o m e (Fe e n s s-t r a , 1994a ). Th is c a n o n ly b e e n s u r e d b y t h e in t e gr a t io n o f le p ro sy se rvice s.
• Alt h o u gh M D T h a s n o t h a d a s ign ific a n t a d d it io n a l im p a c t o n t r a n s m is s io n , it h a s
p r o ve n t o b e a n e xc e lle n t t r e a t m e n t r e gim e n fo r le p ro sy p a t ie n t s. Sid e e ffe ct s a re ra re ly se e n , a n d t h e n u m b e r o f r e la p se s is lim it e d . Th e u se o f b list e r p a cks h a s m a d e it s u t iliza t io n sim p le for b oth h ea lth sta ff a n d p a tien ts, a n d its m o n t h -ly d is t r ib u t io n o ffe r s a go o d o p p o r t u n it y t o r e gu la r ly r e vie w le p r o s y p a t ie n t s , t o d e t e c t o r t r e a t e a r ly n e r ve fu n c t io n im p a ir m e n t , t o a s s e s s d is a b ilit ie s , a n d t o p r o vid e h e a lt h e d u c a -t io n . Th e r e la -t ive s im p lic i-t y o f -t h e a p p lic a -t io n o f M D T fa c ilit a t e s it s u s e b y ge n e r a l h e a lt h w o r ke r s a n d , t h u s , t h e o p p o r t u n it ie s fo r in t e -gra t io n .
• Th e WH O ca m p a ign t o e lim in a t e le p r o sy a s a p u b lic h e a lth p ro b le m h a s ra ise d co m m itm e n t fo r in t e gr a t io n . M a n y c o u n t r ie s r e a lize d t h a t e lim in a t io n c o u ld o n ly b e a c h ie ve d if t h e le p -ro sy services were exp a n d ed (Neira & Da u m erie, 2000). Exp a n sio n o f co vera ge, h o wever, ca n o n ly b e a cco m p lish e d b y in t e gra t in g t h e le p ro sy se r -vic e s in t o t h e ge n e r a l h e a lt h s e r -vic e s . On t h e o t h e r h a n d , it is like ly t h a t t h e c o m m it m e n t t o le p r o s y c o n t r o l w ill d im in is h in t h e c o m in g ye a r s . Th e WH O e lim in a t io n c a m p a ign h a s r e -s u lt e d in t h e m i-s c o n c e p t io n t h a t t h e le p r o -s y p r o b le m c a n b e s u b s t a n t ia lly r e d u c e d in t h e sh o rt term (An o n ym o u s, 1997; Feen stra , 1994b ). Wh e n WH O a d o p t e d a r e s o lu t io n t o e lim in a t e le p r o s y a s a p u b lic h e a lt h p r o b le m b y t h e ye a r 2000, e lim in a t io n w a s d e fin e d a s a r e gis t e r e d p r e va le n c e b e lo w o n e c a s e p e r 10,000 in h a b i-t a n i-t s. U n fo r i-t u n a i-t e ly, i-t h e r e is n o e vid e n c e i-t h a i-t r e a c h in g su c h a p r e d e fin e d p r e va le n c e will r e -d u c e t r a n s m is s io n , in c i-d e n c e , o r t h e a n n u a l
Fig ure 1
Le p ro sy tre nd in the 32 mo st e nd e mic c o untrie s c o mb ine d .
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n u m b e r o f n e w ca se s (ILA/ TF, 2002; Lo ckwo o d , 2002). Th e u se o f re giste re d p re va le n ce a s a n in d ic a t o r fo r t h e m a gn it u d e o f t h e le p r o s y p r o b lem a lso h a s severa l fla ws (Declercq , 2001; Feen -s t r a , 1994b ; ILA/ TF, 2002; Vi-s -s c h e d ijk e t a l., 2000). In fa ct, th e su cce ss in a ch ie vin g a co n sid -e r a b l-e r -e d u c t io n in r -e gis t -e r -e d p r -e va l-e n c -e m a y fe e d t h e id e a t h a t t h e “le p ro sy p ro b le m ” is o ve r a n d m igh t t h u s le a d t o r e d u c e d c o m m it m e n t a n d fin a n c ia l s u p p o r t fr o m go ve r n m e n t s a n d d o n o r s (Fe e n st r a , 1994b ). H e n c e , le p r o sy c o n -t r o l p r o gr a m s n e e d -t o b e c o m e c o s -t - e ffe c -t ive a n d le s s d o n o r d e p e n d e n t , e .g., b y in t e gr a t in g th em in to th e gen era l h ea lth services.
• An o t h e r re a so n fo r re d u ce d co m m it m e n t t o le p r o s y c o n t r o l is t h a t o t h e r d is e a s e s s u c h a s AID S, m a la r ia , t u b e r c u lo sis, a n d n o n c o m m u -n ic a b le d is e a s e s a r e c u r r e -n t ly r e ga r d e d a s t h e p r io r it ie s (Gr e e n & Jo c h e m , 1998; Vis s c h e d ijk e t a l., 2000). Th is m a y le a d t o a sit u a t io n wh e re se rvice s fo r n e w le p ro sy p a t ie n t s will d isa p p e a r o r lo s e q u a lit y in t h e fu t u r e . Be t t e r c o lla b o r a -t io n w i-t h o -t h e r d is e a s e c o n -t r o l p r o gr a m s a n d in t e gr a t io n a t t h e se r vice d e live r y le ve l ca n e n -s u r e t h a t le p r o -s y -s e r vic e -s a r e m a in t a in e d . Fo r in st a n ce , co m b in a t io n o f le p r o sy a n d t u b e r cu lo sis c o n t r o l a c t ivit ie s su c h a s t r a in in g a n d su -p e r vis io n c a n in s o m e s e t t in gs b e m u t u a lly b e n e ficia l (Cro ft & Cro ft , 1997).
• Le p r o s y s e r vic e s a r e d e p e n d e n t o n t h e h e a lt h s ys t e m s t h r o u gh w h ic h t h e y a r e im p le-m e n t e d , p a r t ic u la r ly in t e r le-m s o f t h e ir a c c e s s i-b ilit y a n d q u a lit y. H o we ve r, h e a lt h syst e m s a re c h a n gin g in m a n y c o u n t r ie s (Be r m a n , 1996). Su c h c h a n ge s , w h ic h a r e o ft e n r e fe r r e d t o a s “h e a lt h se c t o r r e fo r m s” (H SR), o ft e n e n t a il t h e d e c e n t r a liz a t io n o f r e s p o n s ib ilit ie s t o lo w e r le ve ls a n d t h e in vo lve m e n t o f t h e p riva t e se ct o r (Be rm a n , 1996; Gre e n & Jo ch e m , 1998). De ce n -t r a liza -t io n o f r e s p o n s ib ili-t ie s c a n e n h a n c e -t h e o w n e r s h ip o f le p r o s y c o n t r o l a t t h e lo w e r le v-e ls, a n d t h u s t h v-e in t v-e gra t io n p ro cv-e ss, a s wa s t h v-e c a s e in Gh a n a (Ba in s o n , 1994). P r iva t e s e c t o r in vo lve m e n t , p a r t ic u la r ly in u r b a n s e t t in gs , ca n e n h a n ce t h e a cce ssib ilit y o f a n d co lla b o ra -t io n wi-t h a co n sid e ra b le se gm e n -t o f h e a l-t h ca re p r o vid e r s (U p le ka r & Ca s h , 1991). In s u c h s e t-t in gs t-t h e o u t-t p a t-t ie n t-t d e p a r t-t m e n t-t s o f h o s p it-t a ls a n d d e rm a t o lo gy clin ics sh o u ld a lso b e in clu d -e d in l-e p ro sy co n t ro l a ct ivit i-e s.
• D e m o gr a p h ic c h a n ge s s u c h a s t h e r is in g n u m b e r s o f e ld e r ly p e o p le (WH O, 2000b ) m a y in cre a se t h e n u m b e r o f e ld e rly d isa b le d le p ro sy p a t ie n t s in n e e d o f t r e a t m e n t a n d c a r e . Su c h d e m a n d s fo r re h a b ilit a t ive se rvice s ca n o n ly b e m e t if t h e s e s e r vic e s a r e in t e gr a t e d , t h e r e b y t a r ge t in g a ll kin d s o f d isa b ilit ie s a n d n o t so le ly o n e sp e cific d ise a se .
• At t h e sa m e t im e , le p ro sy co n t ro l is a ffe ct e d b y s o c io e c o n o m ic d e ve lo p m e n t s a n d t h e ge n -e r a l (h -e a lt h ) p o lic i-e s o f c o u n t r i-e s . Ec o n o m ic c r ise s in se ve r a l c o u n t r ie s a n d t h e c o n se q u e n -t ia l a d ju s -t m e n -t p r o gr a m s m o s -t like ly h a d a n e ga t ive im p a ct o n h e a lt h ca re a n d o n p o ve rt y-r e la t e d d is e a s e s , in c lu d in g le p y-r o s y (Ch a b o t e t a l., 1995). M a n y c o u n t r ie s h a ve n o t b e e n a b le t o p r o t e c t vu ln e r a b le gr o u p s fr o m t h e s e d is-e a s is-e s , a n d o n ly s p is-e n d lim it is-e d a m o u n t s o n h ea lth ca re fo r th e p o o r. Th o u gh m o re re so u rce s sh o u ld b e sp e n t o n h e a lt h ca r e a n d h e a lt h sys-t e m s, sys-t h e sca rce re so u rce s fo r sys-t h e h e a lsys-t h se csys-t o r s h o u ld a ls o b e u s e d in a m o r e e ffe c t ive w a y, e .g., t h ro u gh in t e gra t e d se rvice s.
• Sign ific a n t ge n d e r d iffe r e n c e s e xis t in le p r o sy c o n t r o l, b a se d o n b io lo gic a l a s we ll a s so -cio -cu lt u ra l fa ct o rs (Id a wa n i e t a l., 2002). Th e se c a n h a ve t h e e ffe c t o f r e d u c in g c a s e d e t e c t io n r a t e s fo r wo m e n , a s wo m e n o ft e n h a ve le ss a c-c e s s t o h e a lt h s e r vic-c e s t h a n m e n (Le Gr a n d , 1997). In a d d it io n , t h e so cia lly in fe rio r st a t u s o f w o m e n a n d t h e s t igm a t iz e d d is e a s e r e s u lt in gr e a t e r s o c ia l a n d m e n t a l p r o b le m s (Sh a le , 2000). In t e gra t io n o f le p ro sy se rvice s will m a ke t h e s e r vic e s m o r e a c c e s s ib le a n d c a n r e d u c e th e stigm a o f le p ro sy.
Experiences with integration
of leprosy control
As in d ic a t e d a b o ve , s e ve r a l d e ve lo p m e n t s in le p ro sy co n t ro l a n d t h e h e a lt h se ct o r ju st ify t h e n e e d t o in t e gr a t e le p r o s y s e r vic e s . As a r e s u lt , s e ve r a l c o u n t r ie s h a ve a lr e a d y e m b a r ke d o n a p r o c e s s t o in t e gr a t e le p r o s y c o n t r o l in t o t h e ge n e ra l h e a lt h se rvice s (Fe e n st ra & Vissch e d ijk, 2002). So m e o f t h e se e xp e rie n ce s a re d iscu sse d b elo w. First, th e p ro cess to wa rd s in tegra tio n will b e d is c u s s e d . Th e n , t h e c o n s e q u e n c e s o f in t e gr a t io n o n t h e im p le m e n t a t io n o f le p r o sy c o n tro l a ctivities will b e a ssessed . Fin a lly, sp ecia l a t -t e n -t io n will b e p a id -t o e xp e r ie n ce s fr o m Br a zil.
The process towards integration
In t h is d ist rict t h e ge n e ra l h e a lt h wo rke rs, a ft e r s o m e b a s ic t r a in in g, p r o vid e d d a y t o d a y t u b e r c u lo s is a n d le p r o s y s e r vic e s u n d e r t h e r e -sp o n sib ilit y o f t h e d ist rict h e a lt h se rvice s. Aft e r th is p ilo t d em o n stra ted th a t gen era l h e a lt h st a ff co u ld e ffe ct ive ly im p le m e n t le p ro sy a n d t u b e r-c u lo s is a r-c t ivit ie s , t h e in t e gr a t io n p r o c e s s w a s exp a n d ed to o th er regio n s t h ro u gh o u t t h e co u n -t r y. P ilo -t s m a y a ls o -t a k e s h a p e a s h e a l-t h s ys-t e m r e se a r ch p r o je ct s, in wh ich le sso n s ca n b e le a rn e d fo r t h e in t e gra t io n p ro ce ss (Le ve r e t a l., 1998). In Or issa , In d ia , su ch r e se a r ch wa s u se d t o fin e -t u n e t h e a ct ivit ie s o f a n NGO t o t h e go v-e r n m v-e n t a l h v-e a lt h c a r v-e s t r u c t u r v-e (P o r t v-e r v-e t a l., 2002).
All e xp e r ie n ce s r e ve a l t h a t p r o p e r p la n n in g a n d p re p a ra t io n h a ve t o p re ce d e t h e a ct u a l im -p le m e n t a t io n o f t h e in t e gr a t io n -p r o c e s s . In so m e co u n tries, su ch a s Eth io p ia , a step -b y-st e p a p p ro a ch wa s sp e lle d o u t in d e t a il, in wh ich a ll t h e co n se cu t ive s st e p s we re in d ica t e d (Fe ka d e -s illa -s -s ie e t a l., 1999). Ot h e r im p o r t a n t a -s p e c t -s in t h e p la n n in g a n d p r e p a r a t io n p h a se in clu d e a r e a lis t ic s it u a t io n a n a lys is , c o m m it m e n t b u ild in g, fo r m u la t io n o f a c le a r p la n fo r in t e -gr a t io n , t r a in in g o f h e a lt h w o r ke r s , a n d p r o vi-sio n o f a d e q u a t e a n d t im e ly in fo rm a t io n t o t h e p u b lic.
In Jiga wa Sta te, Nigeria , a n effo rt to in tegra te t h e le p ro sy se rvice s in 1996 fa ile d d u e t o la ck o f c o m m it m e n t fr o m b o t h t h e p o lic ym a ke r s a n d t h e h e a lt h s t a ff (N a m a d i e t a l., 2002). Wh e n in 1999 a n e w o p p o r t u n it y e m e r ge d t h r o u gh t h e im p le m e n t a t io n o f a LEC, t h e fir s t s t e p w a s t o b u ild co m m itm e n t a m o n g th e d e cisio n -m a ke rs. At a la t e r st a ge in t h e p ro ce ss, it wa s a lso p o ssi-b le to co n vin ce th e p re vio u s h e a lth wo rke rs a n d t h e ge n e r a l h e a lt h st a ff o f t h e n e e d fo r in t e gr a-tio n . Th e p ro ce ss a s a wh o le wa s su cce ssfu l.
A s im ila r e xp e r ie n c e s t e m s fr o m Ta m il N a d u , In d ia (Co m m u n it y H e a lt h D e p a r t m e n t , Ch r is t ia n M e d ic a l Co lle ge , 2 0 0 0 ; D AN LEP, 2000; Ra o e t a l., 2002), wh ich wa s t h e first St a t e in In d ia w h e r e in t e gr a t io n w a s im p le m e n t e d . In t h is St a t e , in t e gr a t io n wa s co n d u ct e d im m e -d ia t e ly in o r -d e r t o c ir c u m ve n t t h e p r e va ilin g c lim a t e o f r e s is t a n c e , p a r t ic u la r ly a m o n g ve rt ic a l le p r o s y s rt a ff. Alrt h o u gh s u ffic ie n rt a c c e p -t a n c e fo r in -t e gr a -t io n wa s e ve n -t u a lly a c h ie ve d , s e ve r a l o t h e r o b s t a c le s w e r e e n c o u n t e r e d : (i) t h e ge n e r a l h e a lt h wo r ke r s we r e n o t a d e q u a t e -ly t r a in e d ; (ii) t h e p a t ie n t s a n d c o m m u n it ie s w e r e n o t w e ll in fo r m e d c o n c e r n in g in t e gr a -t io n ; a n d (iii) -t h e r o le s a -t -t h e in -t e r m e d ia r y le v-e l, p a r t ic u la r ly in r v-e la t io n t o s u p v-e r vis io n a n d m o n it o r in g, w e r e n o t c le a r . D u e t o t h e la c k o f t r a in in g, t h e d ia gn o s is a n d r e c o r d - ke e p in g w a s s t ill d o n e b y p r e vio u s ve r t ic a l le p r o s y
wo r ke r s r a t h e r t h a n b y t h e ge n e r a l h e a lt h st a ff. An a d d it io n a l p r o b le m w a s t h a t t h e lin e s fo r r e fe r r a l, p a r t ic u la r ly r e ga r d in g c o m p lic a t io n s, we r e n o t we ll d e fin e d .
Th e s e e xp e r ie n c e s in d ic a t e t h a t t h e b u ild in g o f a d e q u a t e h u m a n ca p a cit y t h ro u gh t ra in -in g is o n e o f t h e m o s t im p o r t a n t fa c t o r s fo r s u c c e s s fu l in t e gr a t io n . Su c h t r a in in g s h o u ld n o t o n ly in c lu d e t h e t r a n s fe r o f s kills a n d kn o wle d ge , b u t sh o u ld a lso cre a t e a p o sit ive a t-t it-t u d e o f h e a lt-t h w o r ke r s t-t o w a r d s le p r o s y a n d le p ro sy p a t ie n t s (Asn a ke e t a l., 2000). Sa u n d e r-so n & Ro ss (2002) in d ica t e t h a t it is st ill su rp ris-in g t h a t ris-in t h e e r a o f c o s t - e ffe c t ive n e s s a n d co st - cu t t in g, t r a in in g is o ft e n n o t we ll p la n n e d a n d is r a r e ly e va lu a t e d in a r a t io n a l m a n n e r . H e n ce , t h e y p r o p o se t h e d e ve lo p m e n t o f a N a t io n a l Tra in in g Pla n fo r Le p ro sy, wit h cle a r o b je c t ive s . Su c h a p la n s h o u ld p a y p a r t ic u la r a t -t e n -t io n -t o -t h e ge n e r a l e d u ca -t io n o f h e a l-t h p e r-s o n n e l. Th ir-s ir-s illu r-s t r a t e d b y t h e e xp e r ie n c e o f Zim b a b w e , w h e r e r e d u c e d kn o w le d ge a n d s kills a ft e r in t e gr a t io n a m o n g d o c t o r s a n d p a r a m e d ic a l s t a ff c o u ld h a ve b e e n a vo id e d if le p ro sy co n t ro l h a d b e e n in co rp o ra t e d in t o t h e cu rricu la o f t h e (p a ra -) m e d ica l t ra in in g sch o o ls r igh t fr o m t h e s t a r t (Wa r n d o r ff & Wa r n d o r ff, 1990).
Th e e xp e r ie n c e o f M ya n m a r c o n fir m s t h a t , wh e n a d e q u a t e ly t r a in e d , ge n e r a l h e a lt h wo r ke rs, ke vke n a t t h ke m o st p ke rip h ke ra l lke vke l, a rke ca p a -b le o f d ia gn o sin g a n d t re a t in g le p ro sy p a t ie n t s. In t h is c o u n t r y it w a s fe lt t h a t t h e le p r o s y s e r-vice s co u ld b e m a d e m o re a cce ssib le a n d m o re e ffe ct ive if p r o vid e d clo se r t o t h e co m m u n it ie s (Ba r u a e t a l., 1999). By u t ilizin g t h e m u lt ip u r p o se m id wive s (wh o re sid e wit h in t h e co m m u -n it ie s) fo r a ct ivit ie s su ch a s ca se d e t e ct io -n a -n d t r e a t m e n t , it wa s p o ssib le t o in t e gr a t e t h e p r e -vio u s ve r t ic a l p r o gr a m in t o t h e ge n e r a l h e a lt h se rvice s.
Th e e xp e rie n ce o f Sri La n ka e m p h a size s t h e im p o r t a n ce o f a p a r t icip a t o r y m e t h o d o lo gy fo r t h e in t e gr a t io n p r o c e s s (Ka s t u r ia r a t c h i e t a l., 2002). Wh e n t h e r e d u ct io n in r e gist e r e d p r e va -le n c e r e q u ir e d gr e a t e r e ffic ie n c y in d e t e c t in g a n d t re a t in g le p ro sy p a t ie n t s, t h e p la n fo r in t e -gr a t io n w a s d e ve lo p e d t h r o u gh a n e xt e n s ive co n su lt a t ive p ro ce ss. Th is p ro ce ss re su lt e d in a ve r y c le a r vis io n a n d w e ll- s t r u c t u r e d s e r vic e s , in w h ic h t h e r o le s a n d r e s p o n s ib ilit ie s o f a ll p a r t ie s w e r e s p e lle d o u t in d e t a il. Am p le t im e w a s p r o vid e d t o d e ve lo p a c le a r a n d t r a n s p a re n t i m p lre m re n t a t i o n p la n . O r g a n i z i n g r re g u -la r m e e t in gs d u r in g a n d a ft e r t h e in t e gr a t io n p r o c e s s e n s u r e d go o d c o m m u n ic a t io n . Fu r-t h e r m o r e , r-t h e r-t r e a r-t m e n r-t s r-t a ff w a s r e o r ie n r-t e d a n d a n a t io n w id e p u b lic a w a r e n e s s c a m p a ign wa s la u n ch e d o n t h e a va ila b ilit y o f le p ro sy se r-vic e s in a ll h e a lt h fa c ilit ie s . Exp e r ie n c e fr o m c o u n t r ie s s u c h a s Ar ge n t in a e m p h a s iz e s t h a t p a t ie n t s ’ kn o w le d ge o f t h e n e w s ys t e m is a n im p o r t a n t fa c t o r fo r s u c c e s s fu l in t e gr a t io n (Me rlin e t a l., 1998).
Re h a b ilit a t io n o f d is a b le d le p r o s y p a t ie n t s a n d e ye ca re fo r le p ro sy p a t ie n t s sh o u ld a lso b e in t e gr a t e d in t o ge n e r a l h e a lt h s e r vic e s a n d fa -c ilit ie s (St ilm a , 1991). Se p a r a t e t r e a t m e n t o f le p ro sy p a t ie n t s will b e in e fficie n t a n d will su s-t a in s-t h e ss-t igm a a n d m isco n ce p s-t io n s-t h a s-t le p ro sy is a sp e cia l d ise a se . Th is m e a n s t h a t su rgica l reh a b ilit a t io n s reh o u ld b e m a d e a va ila b le in ge n -e r a l h o s p it a ls a n d h -e a lt h fa c ilit i-e s , a n d t h a t t ra in in g o f ge n e ra l h e a lt h st a ff in le p ro sy sh o u ld b e m a n d a t o r y (Vir m o n d & Pe r e ir a , 2000). Fu t h e rm o re , a s Ka ze n (1999) in d ica t e s, t h e m a jo rit y o f p a t ie n t s writ h u lce rs in n e e d o f su rgica l in t e rve n t io n ca n b e t re a t e d b y ve ry sim p le p ro ce -d u re s, a n -d p a t ie n t s will b e n e fit fro m t re a t m e n t fa c ilit ie s n e a r t h e ir h o m e s . Se ve r a l a t t e m p t s h a ve a lr e a d y b e e n m a d e t o s t im u la t e c o lla b o -r a t io n b e t w e e n s o c io e c o n o m ic -r e h a b ilit a t io n p ro je ct s a n d ge n e ra l re h a b ilit a t io n fa cilit ie s, o r t o in t e gr a t e t h e fo r m e r in t o t h e la t t e r (Ka t h e e t a l., 1992).
Consequences of the integration
process for leprosy control
At le a st a s im p o rta n t a s th e p ro ce ss a re th e co n -s e q u e n c e -s a n d o u t c o m e -s fo r le p r o -s y c o n t r o l. Th e se o u t c o m e s a r e m o st ly m e a su r e d t h r o u gh in d ic a t o r s su c h a s c a se d e t e c t io n r a t e , p r o p o r-t io n o f p a r-t ie n r-t s wir-t h visib le d isa b ilir-t ie s a m o n g n e wly d e t e ct e d p a t ie n t s, a n d t h e cu re ra t e . U n -fo rtu n a te ly, it is o fte n m e th o d o lo gica lly d ifficu lt t o d e t e rm in e t h e e xa ct im p a ct o f in t e gra t io n o n th ese in d ica to rs, a s th ere a re u su a lly severa l o th
-e r c o n t r ib u t in g fa c t o r s in vo lv-e d in c h a n g-e s in ca se d e te ctio n a n d ca se m a n a ge m e n t. Th e se d a t a a r e u s u a lly a va ila b le , b u t t h e y s h o u ld b e in -terp reted with ca u tio n .
In m o s t s e t t in gs in w h ic h le p r o s y c o n t r o l wa s in t e gra t e d , t h e a cce ssib ilit y in cre a se d su b -s t a n t ia lly. In c o u n t r ie -s -s u c h a -s Et h io p ia a n d N ige r ia w h e r e m u c h e m p h a s is w a s p la c e d o n t h e e xp a n sio n o f se rvice s, t h e n u m b e r o f h e a lt h fa cilit ie s t h a t p ro vid e le p ro sy se rvice s o n a d a y-t o - d a y b a sis h a s r ise n su b sy-t a n y-t ia lly (Fe ka d e sil-la ssie e t a l., 1999; Na m a d i e t a l., 2002). In Jiga wa St a t e , N ige r ia , t h e n u m b e r in c r e a s e d a lm o s t t h r e e fo ld : wh ile 75 h e a lt h fa c ilit ie s we r e o ffe r-in g le p r o s y s e r vic e s r-in 1998, t h is n u m b e r h a d rise n t o 264 in 2000.
Th e c o n s e q u e n c e s o f in t e gr a t io n fo r c a s e d e t e c t io n r a t e s va r ie d b e t w e e n c o u n t r ie s a n d a r e r a t h e r d iffic u lt t o a n a lyze , m o s t ly b e c a u s e t h e se figu re s d e p e n d o n se ve ra l o p e ra t io n a l a s-p e c t s su c h a s t h e in t e n sific a t io n o f a c t ive c a se fin d in g (e .g., t h r o u gh LECs ). Wh e n LECs a r e p a rt o f in t e gra t io n e ffo rt s, t h e n u m b e r o f n e wly d e t e c t e d p a t ie n t s m a y in c r e a s e s u b s t a n t ia lly. H o w e ve r , in t h e ye a r s im m e d ia t e ly fo llo w in g s u c h a n e xe r c is e t h e n u m b e r s m a y d e c r e a s e s o m e w h a t . In Sr i La n ka , w h e r e t h e n u m b e r o f h e a lt h fa c ilit ie s wit h M D T se r vic e s wa s n o t e x-p a n d e d , t h e c a s e d e t e c t io n r a t e in c r e a s e d b y 41% in t h e fir s t ye a r a ft e r in t e gr a t io n (Ka t u r i-a r i-a t c h i e t i-a l., 2002). Th is m i-a y b e d u e t o t h e h e a lt h e d u ca t io n ca m p a ign t h r o u gh wh ich p a -t ie n -t s a n d co m m u n i-t ie s we re in fo rm e d .
Co n ce rn s h a ve b e e n ra ise d a s t o wh e t h e r in -t e gra -t io n o f le p ro sy co n -t ro l m igh -t -t a ke p la ce a -t t h e e xp e n s e o f t h e q u a lit y o f le p r o s y s e r vic e s (N a a fs , 2000). Th o u gh q u a lit y h a s s e ve r a l a s-p e c t s , s u c c e s s in c u r in g s-p a t ie n t s is c e r t a in ly a m o n g t h e m . In s e ve r a l in t e gr a t e d p r o gr a m s (Nige ria , Sri La n ka , Mya n m a r) t h e cu re ra t e h a s b e e n ke p t a t a c c e p t a b le le ve ls (Ba r u a e t a l., 1999; Ka st u r ia r a t ch i e t a l., 2002; N a m a d i e t a l., 2002). H o wever, in Ta m il Na d u , In d ia , p ro b le m s h a ve o ccu r r e d in d e a lin g wit h co m p lica t e d p a -t ie n -t s a n d re fe rra l sys-t e m s (DANLEP, 2000).
Ad d it io n a l r e s e a r c h m a y b e n e e d e d t o b e t -t e r a s s e s s -t h e c o n s e q u e n c e s o f in -t e gr a -t io n fo r t h e q u a lit y o f le p r o s y s e r vic e s . Su c h c o n t e xt sp e c ific r e se a r c h sh o u ld in d ic a t e h o w in t e gr a -t io n is a ffe c-t in g -t h e m o t im p o r -t a n -t q u a li-t y a s-p e c t s o f le s-p r o s y s e r vic e s a n d h o w q u a lit y c a n b e m a in t a in e d a n d s t r e n gt h e n e d in a n in t e -gra t e d se t t in g.
Th e p a ra m e t e rs fo r a sse ssin g q u a lit y we re : a d e -q u a c y o f d ia gn o s is , P B/ M B c la s s ific a t io n , a n d c h a n ge in d is a b ilit y s t a t u s d u r in g t r e a t m e n t . Th e s t u d y r e ve a le d n o s u b s t a n t ia l c h a n ge s in th e a ccu ra cy o f d ia gn o sis a n d cla ssifica tio n , a n d n o ch a n ge in d isa b ilit y st a t u s b e t we e n p re - a n d p o s t - in t e gr a t io n . Th is in d ic a t e s t h a t q u a lit y o f le p ro sy se rvice s ca n b e m a in t a in e d a t a re a so n -a b le level fo llo win g in tegr-a tio n .
An o t h e r a sp e ct t h a t st r o n gly in flu e n ce s t h e c o u r s e o f le p r o s y is e a r ly d e t e c t io n a n d t r e a t-m e n t o f r e a c t io n s . Th is c le a r ly r e q u ir e s t-m o r e r e se a r ch , sin ce e xp e r ie n ce t o d a t e d o e s n o t in -d ic a t e h o w in t e gr a t io n a ffe c t s t h is im p o r t a n t a sp e ct o f le p ro sy co n t ro l.
All e xp e r ie n ce s h igh ligh t t h e im p o r t a n ce o f m a in t a in in g a d e q u a t e s u p p o r t s e r vic e s a ft e r in t e gr a t io n h a s b e e n c o m p le t e d . Co n t in u o u s s u p e r vis io n , t e c h n ic a l s u p p o r t , a n d m o n it o r-in g a r e c r u c ia l t o m a r-in t a r-in go o d s t a n d a r d s o f le p r o s y s e r vic e s . Su c h s u p p o r t s h o u ld b e p r o vid e d m o st ly b y t h e in t e rm e d ia t e le ve l (p ro vin cia l a n d d ist rict ). Tra in in g m u st a lso b e co n t in -u e d t o co m p e n sa t e fo r a t t rit io n o f h e a lt h wo rk-e r s a n d t o rk-e n su r rk-e t h a t skills a n d kn o wlrk-e d grk-e a rrk-e su st a in e d (Ch e n e t a l., 2000).
Integration of leprosy services in Brazil
In Bra zil, in t e gra t io n o f le p ro sy co n t ro l in t o t h e ge n e ra l h e a lt h se rvice s b e ga n in t h e 1980s (MS, 2001). Pr e vio u s ly, le p r o s y c o n t r o l wa s t h e r e-sp o n sib ility o f th e Fed era l level. Clin ica l services w e r e p r o vid e d b y d e r m a t o lo gis t s a n d le p r o lo -gists, a n d so cia l ca re fo r lep ro sy p a tien ts wa s o f-t e n p r o vid e d b y c h u r c h - r e la f-t e d o r ga n iza f-t io n s. In t e gr a t io n o f le p r o s y s e r vic e s w a s p a r t o f a b ro a d e r, fe d e ra lly in it ia t e d e xe rcise co m p risin g in t e gra t io n o f t h e m o st re le va n t h e a lt h se rvice s in t o a p rim a ry h e a lt h ca re syst e m . It wa s n o t a n iso la t e d p ro ce ss co n fin e d t o le p ro sy co n t ro l, a s wa s th e ca se in so m e o th er co u n tries.
A first d e fin it e st e p wa s t a ke n in 1990, wh e n t h e s e r vic e s w h e r e d e c e n t r a liz e d . P r e vio u s ly, t h e p u b lic h e a lt h syst e m in Br a zil wa s c e n t r a l-ize d in t h e Fe d e r a l go ve r n m e n t a n d c o n s is t e d o f t w o d is t in c t s e r vic e s ys t e m s , o n e u n d e r t h e M in is t r y o f So c ia l Se c u r it y a n d We lfa r e , t h e o t h e r o n e u n d e r t h e M in ist r y o f H e a lt h (M o H ). In 1990 t h e s e t w o s ys t e m s w e r e u n it e d u n d e r t h e M in is t r y o f H e a lt h , a n d t h e ir c o n s t it u e n t h e a lt h fa cilit ie s we r e h a n d e d o ve r t o t h e St a t e s a n d m u n ic ip a lit ie s . Wit h t h e e s t a b lis h m e n t o f t h is N a t io n a l U n ifie d H e a lt h Syst e m (SU S), t h e st ru ct u re fo r in t e gra t io n wa s a ct u a lly cre a t e d .
Th e in t e n t io n is fo r t h e SU S t o b e a d e c e n t r a lize d , r e gio n a l s e r vic e s ys t e m , c o m p r e h e n
sive in t e r m s o f cu r a t ive , p r e ve n t ive , a n d r e h a -b ilit a t ive se rvice s, a n d e q u it a -b le in t e rm s o f t h e n e e d s o f va r io u s c o m m u n it ie s . U n d e r t h e SU S th e m u n icip a lities a re n o w resp o n sib le fo r p la n -n i-n g, o rga -n iza t io -n , m o -n it o ri-n g, a -n d e va lu a t io -n o f h e a lt h a ct ivit ie s a n d se rvice s. Th e St a t e le ve l is re sp o n sib le fo r co o rd in a t in g a n d m o n it o rin g a ll a c t ivit ie s . St a t e s p r o vid e t e c h n ic a l a n d fi-n a fi-n c ia l c o o r d ifi-n a t io fi-n fo r t h e a c t ivit ie s b y t h e m u n ic ip a lit ie s . Th e Fe d e r a l le ve l fo r m u la t e s a n d e va lu a t e s n a t io n a l h e a lt h p o licie s, e n su re s t h e u n ifo r m it y o f t h e syst e m , a n d r e gu la t e s r e -la t io n s b e t we e n t h e p u b lic a n d p riva t e se ct o rs. A n e xt s t e p t o w a r d s in t e gr a t io n w a s t a ke n a ft e r 1992, w it h t h e a c t u a l d e c e n t r a liza t io n o f e xe c u t ive p o w e r s t o m u n ic ip a l le ve l. Th is w a s a c h ie ve d t h r o u gh t h e Fa m ily H e a lt h P r o gr a m (P SF), e s t a b lis h in g m o r e fu n c t io n a l a s p e c t s o f in t e gr a t io n . Th e P SF is im p le m e n t e d t h r o u gh t e a m s co n sist in g o f a p h ysicia n , n u rse , n u rsin g a id e , a n d 4-6 co m m u n it y h e a lt h wo rke rs (agen -t es com u n i-t ários d e saú d e: ACS). Th e ir t a sks a re t o p ro vid e b a sic h e a lt h ca re , d e ve lo p h e a lt h e d -u ca t io n a ct ivit ie s, p ro m o t e co m m -u n it y p a rt ici-p a t io n , id e n t ify in d ivid u a l a n d co lle ct ive h e a lt h risks, a n d m o n it o r d e m o gra p h ic a n d e p id e m io -lo gica l tre n d s. Th e a ctivitie s in clu d e h o m e visits a n d p a r t ic ip a t io n in c o m m u n it y d e ve lo p m e n t . A PSF t e a m c a r e s fo r a p p r o xim a t e ly 4,500 p e o -p le a n d a ls o h a s le -p r o s y c o n t r o l r e s -p o n s ib ilit ie s. Co m m u n iilit y h e a lilit h wo rke rs p la y a n im p o r t a n t r o le in le p r o s y c a s e h o ld in g a n d t h e p r o -m o t io n o f s e lf- r e p o r t in g o f s u s p e c t e d le p r o s y ca se s. Tra in in g a n d su p e rvisio n o f t h e PSF st a ff is t h e r e s p o n s ib ilit y o f t h e m u n ic ip a l h e a lt h s e c r e t a r y, r e gio n a l s u p e r vis o r s , a n d St a t e a n d n a t io n a l c o o r d in a t o r s , s u p p o r t e d b y a p o o l o f t r a in e r s fr o m u n ive r sit ie s. Se ve r a l n o n go ve r n m e n t a l o rga n iza t io n s (NGOs) co n t rib u t e t o fu r -th e r le p ro sy-o rie n te d tra in in g a ctivitie s.
Th e PSF h a s b e e n s u c c e s s fu lly im p le m e n t -e d in s -e v-e r a l St a t -e s . In M in a s G-e r a is , w it h o n -e o f t h e s t r o n ge s t St a t e e c o n o m ie s in Br a zil, t h e PSF st a rt e d in 1994 a n d n o w co ve rs 674 m u n ic-ip a litie s (79% o f th e Sta te ). Mo re th a n two t h o u -s a n d t e a m -s a r e o p e r a t io n a l, r e a c h in g 45% o f t h e p o p u la t io n . Th e t e a m s a r e a ssist e d b y a t o -t a l o f 1 7 ,0 0 0 c o m m u n i-t y h e a l-t h w o r ke r s w h o co ve r 57% o f t h e p o p u la t io n .
-p e rvisio n is h a m -p e re d b y lim it e d t e ch n ica l a n d fin a n c ia l c a p a c it y a t t h e in t e r m e d ia t e le ve l, a n d t h e PSF t e a m s a re n o t a lwa ys we ll su p p o rt-e d o n t rt-e c h n ic a l is s u rt-e s . St a t rt-e - lrt-e vrt-e l s u p rt-e r vis io n ca p a cit y is a va ila b le in so m e St a t e s d u e t o su p -p o r t b y N GOs . Fin a lly, c u r r e n t t r a in in g e ffo r t s d o n o t a lwa ys re su lt in PSF t e a m s t h a t a re su ffi-c ie n t ly ffi-c o n fid e n t t o a ffi-c t u a lly d ia gn o s e t h e d is-e a sis-e o r in it ia t is-e lis-e p ro sy t ris-e a t m is-e n t .
In t h is s ys t e m t h e d is t r ib u t io n o f le p r o s y d r u gs is t h e r e s p o n s ib ilit y o f t h e Fe d e r a l go ve r n m ve n t a n d is c a r r ive d o u t w it h o u t in t ve r r u p -t io n via -t h e n a -t io n a l ch a n n e ls. Le p r o sy co n -t r o l d a t a a r e e n t e r e d in t o t h e SIN AN r e gis t r a t io n s ys t e m . Th e SIN AN c o m p u t e r ize d n o t ific a t io n s ys t e m c o lle c t s a r e la t ive ly c o m p r e h e n s ive s e t o f c lin ic a l- a n d p u b lic h e a lt h - o r ie n t e d d a t a o n co m m u n ica b le d ise a se s, in clu d in g le p ro sy, a n d is a go o d e xa m p le o f a n in t e gra t e d in fo rm a t io n syst e m . Ot h e r m a jo r n a t io n a l d a t a syst e m s a r e th e In fo rm a tio n System o n Mo rta lity (SIM), Live Bir t h s (SIN ASC), H o s p it a l D a t a (SIH ), O u t p a t ie n t D a t a (SIA/ SU S), a n d s u p p o r t fo r t h e N a -t io n a l Im m u n iza -t io n Pro gra m (API).
Le p r o sy co n t r o l wa s fu r t h e r in t e gr a t e d in t o t h e ge n e r a l h e a lt h se r vice s in 2001 wh e n a n e w la w kn o wn a s th e H ea lth Ca re Op era tio n a l No rm w a s im p le m e n t e d , t h u s le ga lly c la s s ifyin g le p -ro sy co n t-ro l a s a b a sic h ea lth service. Th is m e a n t t h a t e ve r y b a sic h e a lt h u n it is r e q u ir e d t o c o n -d u ct le p ro sy co n t ro l sim ila r t o o t h e r co m m u n i-c a b le d is e a s e s s u i-c h a s t u b e r i-c u lo s is a n d H IV/ AIDS. Th e la w a lso h a s p o sit ive im p lica t io n s fo r p o lit ic a l c o m m it m e n t a n d t h e m o b iliza t io n o f fu n d s.
In a d d it io n , t h r o u gh a Fe d e r a l in it ia t ive , a N a t io n a l M o b iliza t io n Pr o je c t fo r t h e Elim in a -t io n o f Le p r o sy (a n d -t h e Co n -t r o l o f Tu b e r c u lo-s ilo-s ) ilo-s b e in g im p le m e n t e d , p a r t ic u la r ly t a r ge t-in g p rio rit y m u n icip a lit ie s. Th e first st a ge is t h e m o b iliza t io n a n d c o o r d in a t io n o f p o lit ic a l a n d m a n a ge r ia l le ve ls a t t h e St a t e a n d m u n ic ip a l le ve ls. So m e o f t h e a ct ivit ie s a re co m b in e d a n d c o n c e r n b o t h le p r o sy a n d t u b e r c u lo sis. Ob je c-t ive s a n d a cc-t ivic-t ie s in clu d e : c-t e ch n ica l, p o lic-t ica l, a n d s o c ia l m o b iliz a t io n t o w a r d s t h e go a ls o f le p r o s y e lim in a t io n a n d t u b e r c u lo s is c o n t r o l; d e c e n t r a liz a t io n o f a c t ivit ie s a n d r e o r ga n iz a -t io n o f s e r vic e s ; im p r o ve m e n -t o f s u r ve illa n c e a n d t h e in fo r m a t io n s ys t e m ; r e in fo r c e m e n t o f t h e n e t w o r k o f la b o r a t o r y a n d d ia gn o s t ic s e r-vic e s ; gu a r a n t e e o f p h a r m a c e u t ic a l a s s is t a n c e t h r o u gh d e ce n t r a lize d d ist r ib u t io n a n d st o cks; a n d h u m a n re so u rce s d e ve lo p m e n t a n d ca p a c-it y-b u ild in g.
Fo r a gr o w in g n u m b e r o f p a t ie n t s , t h e fo l-lo win g ro u t in e h a s n o w b e co m e a re a lit y in se v-e r a l m u n icip a lit iv-e s: su sp v-e ct v-e d ca sv-e s, a s id v-e n t
i-fie d b y c o m m u n it y h e a lt h w o r ke r s , fin d t h e ir w a y t o o n e o f t h e ge n e r a l h e a lt h c a r e w o r ke r s fr o m a fa m ily h e a lt h t e a m in a h e a lt h c e n t e r . Th e d ia gn o sis ca n b e m a d e in m o st ce n t e rs a n d t re a t m e n t , in clu d in g fo llo w- u p , ca n b e st a rt e d . In le ss e xp e r ie n c e d t e a m s o r in c lin ic a lly m o r e d iffic u lt s it u a t io n s , t h e s u s p e c t e d c a s e is r e -fe r r e d . Aft e r d ia gn o s is a n d t h e b e gin n in g o f t re a t m e n t , t h e fa m ily h e a lt h t e a m ca n t re a t t h e p a t ie n t s fu r t h e r in t h e ir o wn m u n icip a lit y. Th e t a sk is t o d e t e ct co m p lica t io n s a t a n e a rly st a ge a n d to stim u la te tre a tm e n t a d h e re n ce . All t h e se se r vic e s a r e su p p o r t e d b y st r o n g St a t e a n d n a -t io n a l le ve ls wh ich d e ve lo p p o licie s, co o rd in a -t e a ll le p ro sy a ctivitie s, m o n ito r th e a ch ie ve m e n t s, a n d p r o vid e t e c h n ic a l s u p p o r t (s u p e r vis io n a n d t ra in in g) t o t h e lo we r le ve ls.
Lessons learned
Ba se d o n t h e e xp e r ie n c e s o u t lin e d a b o ve , se v-e ra l lv-e sso n s ca n b v-e lv-e a rn v-e d , rv-e la tin g to th v-e o ve r a ll p r o c e s s , n e c e s s a r y p r e c o n d it io n s fo r in t e -gra t io n , d e ve lo p m e n t o f a n a d e q u a t e p la n , a n d a p p ro p ria t e p re p a ra t io n s.
The overall process
• In t e gr a t io n r e q u ir e s c a r e fu l a n d a d e q u a t e a d va n ce p la n n in g a n d sh o u ld b e in t ro d u ce d o n a s t e p - b y- s t e p b a s is (p h a s in g in p la c e , t im e , a n d a ct ivit ie s).
• In t e gr a t io n m u st b e co n t e xt - sp e cific. • Th e in t e gr a t io n p r o c e s s s h o u ld b e im p le m e n t e d in a s t e p w is e m o d e , a n d it is im p o r -t a n -t -t o a c h ie ve e a r ly r e s u l-t s . Th is is n e c e s s a r y t o m a in t a in co m m it m e n t .
• Sp e cia l in it ia t ive s su ch a s LECs ca n b e u se d a s o p p o r t u n it ie s t o b e gin o r st r e n gt h e n t h e in -t e gra -t io n p ro ce ss.
• H e a lt h s ys t e m s r e s e a r c h c a n b e u s e fu l t o id e n t ify a n d a d d r e s s o b s t a c le s in t h e in t e gr a -t io n p ro ce ss.
• Th e d o c u m e n t e d e xp e r ie n c e s fr o m o t h e r co u n tries sh o u ld b e b etter u tilized , even t h o u gh t h e in t e gr a t io n p r o c e ss n e e d s t o b e a d a p t e d t o lo ca l sit u a t io n s.
Preconditions
• St a ff a n d p u b lic a c c e p t a n c e o f le p r o s y p a -t i e n -t s i n g e n e r a l h e a l-t h fa c i li -t i e s , a n d w i ll-i n g n e s s o f le p r o s y p a t ll-i e n t s t o a t t e n d t h e s e fa c ilit ie s .
• N GOs su p p o r t in g le p r o sy c o n t r o l c o n t in u e t o b e im p o rt a n t p a rt n e rs o f go ve rn m e n t s in in -t e gr a -t e d le p r o s y c o n -t r o l p r o gr a m s . If d o n o r s w is h t o e n s u r e t h e e s t a b lis h m e n t o f s u s t a in -a b le le p r o sy se r vice s, t h e y m u st wo r k wit h -a n d st re n gt h e n t h e n a t io n a l ge n e ra l h e a lt h se rvice s syst e m .
• In o r d e r t o e s t a b lis h s u s t a in a b le s e r vic e s , b r o a d o w n e r s h ip o f t h e s t r a t e gy m u s t b e a s-su r e d , b o t h wit h in t h e sp e c ific le p r o sy o r ga n i-z a t io n s a n d , e q u a lly im p o r t a n t , o u t s id e . It is im p o rt a n t t h a t t h e va rio u s a ge n cie s in vo lve d in lep ro sy co n tro l co lla b o ra te a n d co o rd in a te t h e ir a c t ivit ie s , in o r d e r t o in c r e a s e t h e ir e ffe c t ive -n e ss.
Development of an adequate plan
• In in t e gr a t in g le p r o s y c o n t r o l in t o ge n e r a l h e a lt h s e r vic e s , e q u it y a n d q u a lit y o f c a r e fo r le p r o s y p a t ie n t s s h o u ld b e a s s u r e d . Th is im p lie s t h a t se r vic e s fo r le p r o sy p a t ie n t s (in c lu d -in g d ia gn o s is , t r e a t m e n t , a n d r e h a b ilit a t io n ) s h o u ld p r o vid e t h e s a m e le ve l o f q u a lit y (n o t le s s , b u t a ls o n o t m o r e ) a s s e r vic e s fo r o t h e r h e a lt h p ro b le m s.
• Su ffic ie n t c a p a c it y in le p r o s y c o n t r o l m u s t b e a va ila b le w it h in t h e ge n e r a l h e a lt h s e r vic e a t t h e ce n t ra l a n d in t e rm e d ia t e le ve ls fo r a d vo -c a -c y, p o li-c y fo r m u la t io n , t e -c h n i-c a l gu id a n -c e , t ra in in g, p la n n in g, m o n it o rin g, e va lu a t io n , a n d c o o r d in a t io n o f n a t io n a l a n d in t e r n a t io n a l d o n o r su p p o rt . Wh e re ve r a va ila b le , d e rm a t o lo -gis t s c a n p la y a n im p o r t a n t r o le in r e fe r r a l, clin ica l gu id a n ce , a n d t ra in in g.
• Th e in c o r p o r a t io n o f le p r o s y in t o t h e c u r-r ic u la o f m e d ic a l fa c u lt ie s a n d p a r-r a m e d ic a l sch o o ls is e sse n t ia l fo r t h e su cce ssfu l o p e ra t io n o f le p r o s y c o n t r o l a s a n in t e gr a t e d p a r t o f t h e ge n e r a l h e a lt h s e r vic e s , a n d t o s u s t a in le p r o sy e xp e rt ise wit h in t h e h e a lt h se rvice s.
• Th e p riva t e fo r-p ro fit h e a lt h se ct o r will p la y a n in c r e a s in g r o le in t h e p r o vis io n o f le p r o s y services. Th is m a y p o se p ro b lem s, su ch a s tre a t -m e n t b y n o n - s t a n d a r d r e gi-m e n s , in c o -m p le t e t r e a t m e n t , in a d e q u a t e in st r u c t io n s t o p a t ie n t s a n d t h e co n se q u e n t risk o f d ru g re sist a n ce , a n d in c r e a s e d in c id e n c e o f d is a b ilit y. N a t io n a l s t r a t e gie s s h o u ld t h e r e fo r e c le a r ly d e fin e t h e p r iva t e s e c t o r ’s r o le , in c lu d in g t r a in in g a n d q u a lit y co n t ro l.
Adequate preparations
• An a d e q u a t e , we ll p r e p a r e d su p p o r t st r u c t u r e a t t h e in t e r m e d ia t e le ve l is n o t o n ly r e q u ir e d w h e n le p r o s y s e r vic e s h a ve b e e n in t e -gr a t e d in t o t h e ge n e r a l h e a lt h s e r vic e s , b u t is a ls o n e c e s s a r y t o p r o vid e gu id a n c e d u r in g t h e in t e gra t io n p ro ce ss.
• Wit h in t e gr a t io n , t h e r e co r d in g a n d r e p o r t-in g s ys t e m w ill r e q u ir e s im p lific a t io n t o a llo w fo r a p p r o p r ia t e d a t a c o lle c t io n b y p e r ip h e r a l m u lt ip u rp o se h e a lt h wo rke rs. On ly d a t a d ire ctly lin ke d t o d e c is io n m a kin g s h o u ld b e r o u -t in e ly co lle c-t e d . Th e n u m b e r o f fo r m s, r e p o r -t s, o r r e gis t e r s s h o u ld b e r e d u c e d t o a m in im u m a n d s h o u ld b e in c o r p o r a t e d in t o a n e xis t in g ge n e r a l h e a lt h m a n a ge m e n t in fo r m a t io n s ys-t e m . A sim p lifie d r e c o r d in g a n d r e p o r ys-t in g syst e m , in co rp o ra syst e d in syst o syst h e ge n e ra l h e a lsyst h m a n -a ge m e n t in fo r m -a t io n s ys t e m , s h o u ld b e in p la ce b e fo re in t e gra t io n is p e rfo rm e d .
• Th e t a s ks o f d iffe r e n t c a t e go r ie s o f s t a ff in t h e in t e gr a t e d p r o gr a m (in c lu d in g p r e vio u s ve r t ic a l s t a ff) s h o u ld b e c le a r ly d e fin e d a n d co m m u n ica t e d t o a ll co n ce rn e d lo n g b e fo re in -t e gr a -t io n is c o n d u c -t e d . Th e s a m e a p p lie s fo r t r a in in g: a ll c a t e go r ie s o f s t a ff s h o u ld h a ve c o m p le t e d t h e ir t r a in in g b e fo r e t h e in t e gr a t e d p r o gr a m b e co m e s o p e r a t io n a l.
• An u n in t e r r u p t e d s u p p ly o f a n t i- le p r o s y d ru gs m u st b e gu a ra n t e e d .
• A p ro fe ssio n a l a d ve rt isin g ca m p a ign t o cre a te a wa ren ess o f th e a va ila b ility o f lep ro sy trea t -m e n t a t a ll h e a lt h fa c ilit ie s , a s we ll a s t o o ve r-co m e th e stigm a a tta ch ed to lep ro sy, ca n stro n g-ly fa cilita te a su ccessfu l in tegra tio n p ro cess.
Towards a model for integration
of leprosy services
Alt h o u gh it is c r u c ia l t o a n a lyz e p a s t e xp e r i-e n c i-e s , t h i-e y o n ly b i-e c o m i-e r i-e li-e va n t if u t ilizi-e d in fu t u r e in t e gr a t io n p r o ce sse s. H e n ce a m o d e l is p r e s e n t e d t h a t c a n a s s is t c o u n t r ie s a n d St a t e s in in t e gr a t in g le p r o s y c o n t r o l in t o ge n e r a l h e a lt h se r vic e s o r in im p r o vin g t h e a lr e a d y in -t e gr a -t e d le p r o s y s e r vic e s . Th e m o d e l is b a s e d o n r e c e n t e xp e r ie n c e s a n d c o m m o n m a n a ge -m e n t a n d p la n n in g p r in c ip le s . Th is -m o d e l is c u r r e n t ly u n d e r r e vie w b y t h e ILEP Te c h n ic a l Co m m issio n . It is e xp e ct e d t h a t t h e fin a l m o d -e l, in wh ich t h -e -e n t ir-e m -e t h o d o lo gy a n d fu rt h -e r d e t a ils a r e p r o vid e d , w ill b e p u b lis h e d b y t h e e n d o f 2003.
a re p re se n t e d in Ta b le 1. In co u n t rie s wh e re in -t e gr a -t io n is a lr e a d y u n d e r w a y o r s o m e in i-t ia l s t e p s h a ve b e e n t a ke n , it is n o t n e c e s s a r y t h a t t h e p r o c e ss b e gin fr o m sc r a t c h a n d r igid ly fo l-lo w a ll s t a ge s . In s u c h c a s e s it is n e c e s s a r y t o id e n t ify h o w fa r t h e p r o c e s s h a s p r o gr e s s e d , w h e t h e r t h e p r o c e s s h a s b e e n a d e q u a t e , a n d w h ic h s t a ge s s t ill n e e d t o b e c o n d u c t e d o r r e -p e a t e d t o s u c c e s s fu lly e s t a b lis h w e ll- in t e gr a t-e d , t-e fft-e ct ivt-e lt-e p ro sy st-e rvict-e s.
Sin c e e ve r y r e gio n a n d St a t e ge n e r a t e s it s o w n s p e c ific c o n t e xt fo r le p r o s y c o n t r o l p r o gr a m s , t h e n e c e s s a r y fle xib ilit y h a s t o b e o b -se rve d d u rin g t h e in t e gra t io n p ro ce ss. Fu rt h e r-m o r e , t h e p r o c e ss n e e d s t o b e t r a n sp a r e n t a n d m u st in vo lve a ll r e le va n t p a r t n e r s. Th is will fac ilit a t e o w n e r s h ip a n d t h e fac o m m it m e n t t o in -t e gra -t io n .
Stage A – Performing a situation analysis
Th is fir s t s t a ge in c lu d e s fo u r t yp e s o f a n a lys is wh ich a re n e ce ssa ry t o a n a lyze t h e cu rre n t sit u -a t io n -a n d co n t e xt , in o rd e r t o p re p -a re -a p l-a n fo r in t e gr a t io n . Fr e q u e n t ly, p a r t s o f t h is in fo r m a t io n o r a n a lys is a r e a lr e a d y a va ila b le , fo r in -sta n ce in a n n u a l rep o rts a n d eva lu a tio n stu d ies.
1. Epidemiological analysis
Th e e p id e m io lo gica l a n a lysis sh o u ld p ro vid e a n a ccu ra t e im p re ssio n o f t h e le p ro sy p ro b le m fo r th e co m in g yea rs. Fo r th is p u rp o se, a set o f in d i-ca t o rs i-ca n b e se le ct e d wh ich a re ro u t in e ly u se d in le p ro sy p ro gra m s a n d a re su m m a rize d in re-c e n t WH O a n d ILEP p u b lire-c a t io n s (ILEP, 2001). Su ch in d ica t o r s will a lso b e im p o r t a n t la t e r o n , fo r m o n it o r in g t h e in t e gr a t io n p r o c e s s . Th e a n a lysis sh o u ld a lso in c lu d e a n e st im a t e o f t h e cu rre n t a n d fu tu re n u m b e r o f d isa b le d p a tie n ts.
2. Analysis of leprosy services
By u sin g o p e ra t io n a l in d ica t o rs su ch a s ca se d e -t e c -t io n r a -t e s , p r o p o r -t io n o f d is a b ili-t ie s , c u r e r a t e s , o r a n a lyt ic a l m o d e ls s u c h a s t h e P io t m o d e l (P io t , 1967), s e r vic e s c a n b e a s s e s s e d fr o m a p u b lic h e a lt h p e r sp e ct ive . It is a lso u se -fu l t o b rin g in t h e clie n t p e rsp e ct ive (va n Dijk e t a l., in p re ss). Th e st ru ct u re , t a sks, a n d fin a n ce s ca n b e a n a lyze d t h ro u gh a m o re o rga n iza t io n a l a p p r o a ch . In t h is a n a lysis it is im p o r t a n t t o in -d ica t e t h e -d iffe re n t t a sks a n -d re sp o n sib ilit ie s o f t h e va r io u s ca t e go r ie s o f h e a lt h st a ff a n d t o a sse ss h o w th e sse will ch a n ge a s a re su lt o f in te gra -t io n . O f c o u r s e , -t h e h e a l-t h fa c ili-t ie s , lo gis -t ic a l s ys t e m , a n d fin a n c ia l a r r a n ge m e n t s a ls o n e e d t o b e a sse sse d .
3. Analysis of level of integration and the health system
In se ve ra l se t t in gs st e p s m a y a lre a d y h a ve b e e n m a d e t o w a r d s in t e gr a t io n . H e n c e , it is a lw a ys im p o rt a n t t o a sse ss t h e cu rre n t le ve l o f in t e gra -t io n . Th e e x-t e n -t o f in -t e gr a -t io n c a n b e a sse sse d b y u s in g in d ic a t o r s t h a t a r e a ls o u s e fu l w h e n m o n it o r in g t h e in t e gr a t io n p r o c e s s . Exa m p le s o f su ch in d ica t o rs a re :
• Th e p ro p o rt io n o f h e a lt h ce n t e r s wit h MD T b list e r p a cks;
• Th e p r o p o r t io n o f h e a lt h c e n t e r s w h e r e ge n e r a l h e a lt h s t a ff c o n d u c t s d ia gn o s e s a n d p ro vid e s t re a t m e n t t o le p ro sy p a t ie n t s; a n d • Th e p r o p o r t io n o f s u p e r vis o r s p r o vid in g a d e q u a t e t e c h n ic a l s u p p o r t t o t h e ge n e r a l h e a lt h st a ff.
In a d d it io n , a n a s s e s s m e n t o f t h e h e a lt h syst e m sh o u ld b e m a d e t o id e n t ify p o ssib le o b -st a cle s t o in t e gra t io n . If t h e ge n e ra l h e a lt h sys-t e m fu n c sys-t io n s in a d e q u a sys-t e ly a sys-t d iffe r e n sys-t le ve ls (e .g., d u e t o la c k o f c a p a c it y, m a n p o w e r , a t t i-t u d e ), i-t h e n in i-t e gra i-t io n m a y fa il. Qu e si-t io n s i-t h a i-t n e e d t o b e a n swe re d a re :
• Wh a t is t h e c a p a c it y o f t h e c u r r e n t ge n e r a l h e a lt h se rvice s in re la t io n t o le p ro sy co n t ro l? Is t h e c o ve r a ge o f t h e c u r r e n t h e a lt h syst e m a d e -q u a t e ?
• Wh a t s p e c ific o b s t a c le s t o in t e gr a t io n c a n b e e xp e ct e d ? In wh a t se n se is t h e p riva t e se ct o r in vo lve d in le p r o s y c o n t r o l, a n d d o e s in t e gr a -t io n je o p a r d ize -t h e q u a li-t y? D o e s a n y p o li-t ic a l in st a b ilit y h a m p e r t h e in t e gra t io n p ro ce ss?
4. Stakeholder analysis
Th e r o le s o f a ll in vo lve d p a r t ie s c a n b e id e n t ifie d b y m e a n s o f a s t a ke h o ld e r a n a lys is . U n -d e r s t a n -d in g -d iffe r e n t s t a ke h o l-d e r s ’ p o s it io n s Tab le 1
Esse ntial stag e s
A Pe rfo rming a situatio n analysis
B Analyzing we akne sse s, stre ng ths, and p rio ritie s
C Ensuring c o mmitme nt to inte g ratio n b y d e c isio n-make rs
D De ve lo p ing a p lan fo r the inte g ratio n p ro c e ss
E Making p re p aratio ns
F Imp le me nting and mo nito ring
a n d a t t it u d e s t o w a r d s in t e gr a t io n is c r u c ia l t o e n s u r e t h a t p o s s ib le r e s is t a n c e t o in t e gr a t io n is m in im ize d a n d c o n flic t s in la t e r p h a s e s a r e p r e ve n t e d . Re c e n t e xp e r ie n c e s in d ic a t e t h a t p a r t ic u la r ly t h e r e s is t a n c e o f ve r t ic a l le p r o s y s t a ff a n d ge n e r a l h e a lt h w o r ke r s h a s b e e n u n -d e r e s t im a t e -d (N a m a -d i e t a l., 2002; Ra o e t a l., 2002). H o we ve r , p a t ie n t s m a y a lso b e a ve r se t o t h e id e a o f in t e gr a t io n b e c a u s e o f t h e s t igm a o r b e c a u s e t h e y fe e l t h a t t h e y a r e n o lo n ge r “sp e cia l”.
Stage B – Analyzing weaknesses, strengths and priorities
We a kn e sse s a n d st r e n gt h s c a n b e su m m a r ize d b a se d o n t h e p re vio u s sit u a t io n a n a lysis. In a d -d it io n , o p p o r t u n it ie s a n -d p o s s ib le t h r e a t s fo r t h e p ro ce ss t o wa rd s in t e gra t io n ca n b e in d ica t-e d . Th is SWOT (st r t-e n gt h s, wt-e a kn t-e sst-e s, o p p o r-t u n ir-t ie s, r-t h re a r-t s) a n a lysis will a lso h igh ligh r-t r-t h e a sp e ct s in t h e in t e gra t io n p ro ce ss t o wh ich p ri-o rit y sh ri-o u ld b e give n . Th is m igh t in clu d e b u ild -in g co m m it m e n t a m o n g so m e gr o u p s, b u t a lso p e r h a p s st r e n gt h e n in g skills fo r c e r t a in h e a lt h p e rso n n e l. If t h e a n a lysis is in co m p le t e a n d a d -d it io n a l in fo r m a t io n is r e q u ir e -d , t h e n fo c u s e -d a n d r a p id h e a lt h syst e m r e se a r c h m a y p r o vid e a n swe rs t o ce rt a in q u e st io n s.
Stage C – Ensuring decision-makers’ commitment to the principles and process of integration
A cru cia l st a ge in e ve ry p ro ce ss is t o e n su re d e-c is io n - m a ke r s ’ e-c o m m it m e n t t o in t e gr a t io n , w it h o u t w h ic h t h e r is ks o f fa ilu r e a r e gr e a t . Th o u gh c o m m it m e n t b y o t h e r s t a ke h o ld e r s s u c h a s s t a ff a n d p a t ie n t s is a ls o im p o r t a n t , t h is ca n o ft e n b e a d d re sse d a t a la t e r st a ge .
Aft e r d e c is io n - m a ke r s a r e id e n t ifie d , t h e y h a ve t o b e c o n vin c e d o f t h e n e e d a n d c o n d i-t io n s fo r in i-t e gra i-t io n . On e wa y o f a ch ie vin g i-t h is m igh t b e t o o r ga n ize a w o r ks h o p (ILEP, 1997). It is o ft e n r e le va n t t o co n fir m t h e co m m it m e n t in a n e xp lic it wa y, wh e r e b y a ll p a r t ie s in d ic a t e t h e ir co m m it m e n t t o in t e gra t io n . A writ t e n d e -c la r a t io n a t t h e e n d o f a w o r ks h o p -c o u ld b e p r o d u c e d a n d o ffic ia lly e n d o r s e d . H o w e ve r , ca re n e e d s t o b e t a ke n t h a t t h e e xp re sse d co m -m it -m e n t is n o t ju s t w in d o w - d r e s s in g o r t h a t t h e co n ce p t s o f in t e gr a t io n a r e n o t in t e r p r e t e d d ifferen tly.
Stage D – Developing a plan for integration
Ba se d o n t h e sit u a t io n a n a lysis, a p la n fo r in t e-gr a t io n sh o u ld b e d e ve lo p e d . Th is p la n sh o u ld
b e u s e d a s a gu id e fo r t h e p r e p a r a t io n , im p le -m e n t a t io n , a n d e va lu a t io n o f t h e in t e gr a t io n p r o c e ss. It sh o u ld in c lu d e n o t o n ly t h e e xp e c t-e d o u t c o m t-e o f t h t-e p r o c t-e ss, b u t a lso a st r a t t-e gy, w o r k p la n , a n d t im e fr a m e . Th e p la n b u ild s o n t h e sit u a t io n a n a lysis a n d co n sist s o f five st e p s.
1. Formulation of objectives/ targets
A d is t in c t io n s h o u ld b e m a d e b e t w e e n o b je ct ive s a n d ct a r ge ct s in ct e r m s o f ct h e e xp e c ct e d r e -s u lt -s o f le p r o -s y c o n t r o l w h e n t h e -s e r vic e -s a r e in t e gr a t e d , a n d t h e o b je c t ive s o f t h e in t e gr a t io n p ro ce ss it se lf. Ob je ct ive s sh o u ld b e o p e ra -t io n a liz e d in s o fa r a s p o s s ib le in q u a n -t ifia b le t a r ge t s . In fo r m a t io n fr o m t h e s it u a t io n a n a lysis sh o u ld b e u se d t o d e ve lo p a ch ie va b le o b je c -t ive s a n d a d e q u a -t e s-t ra -t e gie s.
Ta r ge t s in r e la t io n t o t h e r e s u lt s o f le p r o s y c o n t r o l in a n in t e gr a t e d se t t in g c a n b e d e fin e d “m o re t ra d it io n a lly” a s d e sira b le re su lt s re la t e d t o e p id e m io lo gica l (ca se d e t e ct io n , p re va le n ce ) a n d m o r e o p e r a t io n a l o u t c o m e s (c a s e h o ld in g a n d POD ). Th e y a r e b a sica lly n o d iffe r e n t fr o m t h o se d e fin e d fo r n o n - in t e gra t e d p ro gra m s. An e xa m p le o f a t a r ge t fo r t h e in t e gr a t io n p r o c e ss c o u ld b e t h e n u m b e r / p r o p o r t io n o f h e a lt h fa -cilit ie s t h a t p ro vid e in t e gra t e d le p ro sy in a d is-t ricis-t o r co u n is-t ry.
2. Formulation of a strategy for leprosy control and an approach for the integration process
Th e fo r m u la t io n o f t h e st r a t e gy sh o u ld im p ly a cle a r st a t e m e n t a b o u t h o w le p ro sy se rvice s will b e p ro vid e d in a n in t e gra t e d se t t in g. Th e d iffe re n t a ct ivit ire s rre la t re d t o ca sre fin d in g, ca sre h o ld -in g, POD, re h a b ilit a t io n , a n d su p p o rt a ct ivit ie s (t ra in in g, su p e rvisio n ) h a ve t o b e d e fin e d . Th is n e e d s t o b e s p e lle d o u t in a le p r o s y c o n t r o l m a n u a l, in wh ich t h e d iffe re n t t a sks a re a lso a l-lo c a t e d t o t h e va r io u s p e r s o n n e l in vo lve d in le p r o sy c o n t r o l. A c o m b in a t io n o f so m e a c t ivi-t ie s , e .g., s u p e r vis io n a n d h e a livi-t h e d u c a ivi-t io n , w it h t h o s e o f o t h e r p r o gr a m s m a y b e c o n s id -e r-e d (Vissch -e d ijk -e t a l., 2000).
