title: Integration of leprosy elimination into primary health care in orissa, India.
abstract: BACKGROUND
  Leprosy was eliminated as a public health problem (<1 case per 10,000) in India by December 2005. With this target in sight the need for a separate vertical programme was diminished. The second phase of the National Leprosy Eradication Programme was therefore initiated: decentralisation of the vertical programme, integration of leprosy services into the primary health care (PHC) system and development of a surveillance system to monitor programme performance.
  
  
  RESULTS
  To study the process of integration a qualitative analysis of issues and perceptions of patients and providers, and a review of leprosy records and registers to evaluate programme performance was carried out in the state of Orissa, India. Program performance indicators such as a low mean defaulter rate of 3.83% and a low-misdiagnosis rate of 4.45% demonstrated no detrimental effect of integration on program success. PHC staff were generally found to be highly knowledgeable of diagnosis and management of leprosy cases due to frequent training and a support network of leprosy experts. However in urban hospitals district-level leprosy experts had assumed leprosy activities. The aim was to aid busy PHC staff but it also compromised their leprosy knowledge and management capacity. Inadequate monitoring of a policy of 'new case validation,' in which MDT was not initiated until primary diagnosis had been verified by a leprosy expert, may have led to approximately 26% of suspect cases awaiting confirmation of diagnosis 1-8 months after their initial PHC visit.
  
  
  CONCLUSIONS
  This study highlights the need for effective monitoring and evaluation of the integration process. Inadequate monitoring could lead to a reduction in early diagnosis, a delay in initiation of MDT and an increase in disability rates. This in turn could reverse some of the programme's achievements. These findings may help Andhra Pradesh and other states in India to improve their integration process and may also have implications for other disease elimination programmes such as polio and guinea worm (dracunculiasis) as they move closer to their elimination goals.
authors.affiliation: London School of Hygiene and Tropical Medicine, London, United Kingdom. ruby.siddiqui@london.msf.org
authors.forename: M Ruby
authors.initials: MR
authors.lastname: Siddiqui
authors.forename: Nageswara Rao
authors.initials: NR
authors.lastname: Velidi
authors.forename: Surendra
authors.initials: S
authors.lastname: Pati
authors.forename: Nilambar
authors.initials: N
authors.lastname: Rath
authors.forename: Akshay K
authors.initials: AK
authors.lastname: Kanungo
authors.forename: Amiya K
authors.initials: AK
authors.lastname: Bhanjadeo
authors.forename: Bandaru Bhaskar
authors.initials: BB
authors.lastname: Rao
authors.forename: Bijaya M
authors.initials: BM
authors.lastname: Ojha
authors.forename: Kodyur
authors.initials: K
authors.lastname: Krishna Moorthy
authors.forename: Douglas
authors.initials: D
authors.lastname: Soutar
authors.forename: John D H
authors.initials: JD
authors.lastname: Porter
authors.forename: Pemmaraju V
authors.initials: PV
authors.lastname: Ranganadha Rao
mesh_terms: D001364:Awareness; D003376:Counseling; D019033:Delivery of Health Care, Integrated / Q000458:organization & administration*; D004359:Drug Therapy, Combination; D006266:Health Education; D006801:Humans; D007194:India / Q000453:epidemiology; D007918:Leprosy / Q000175:diagnosis / Q000453:epidemiology* / Q000517:prevention & control* / Q000628:therapy; D010349:Patient Compliance; D011320:Primary Health Care / Q000458:organization & administration*; D011787:Quality of Health Care; D012042:Registries; D015203:Reproducibility of Results