5)　Prevention and management of disabilities

The example of self-care groups in Ethiopia was mentioned, with the leprosy patients' associations potentially playing an important role in helping to support those groups and assist in the provision of rehabilitation services (both physical, social and economic) . Stigma was discussed, with the feeling that it may perhaps increase in some situations as the endemicity decreases.

In addition to patients' associations, other organizations (e.g. NGO's government welfare departments, etc.) should be involved in providing basic services such as protective footwear.

　

6)　Costs

While there may be many cost savings in an integrated setting, some additional costs must be considered, especially those affecting patients, such as the costs involved in more visits to a referral center, which may be some way away. Payment for items such as footwear is also likely to be required.

While savings may be made, it is likely that the quality of the case management of individual patients will decrease in this situation.

　

7)　Urban and rural areas

While leprosy patients will face different problems in these different settings, it was felt that most are not specific to leprosy; leprosy patients will be similar to other patients in this respect and they will be helped by strengthening the basic health services and the referral system already in place.

　

8)　Monitoring

The major problem in monitoring is usually that too much data is collected. In this situation it was felt that a minimum of information should be routinely reported and any further information requirements would be met by appropriate surveys. The minimum data required are： the number of new cases, the number completing treatment and the number of new cases with grade 2 impairment.

　

9)　Training requirements

Training is required at the peripheral level for suspicion and referral. This has been developed in the field of dermatology, especially in Tanzania. The idea is that the peripheral worker would be trained to identify and treat up to 5 or 6 locally important skin conditions; other skin problems would be referred. This worker would not be taught anything specially about leprosy, except to be able to give out MDT to known leprosy patients.

At the diagnostic level (often at district level), a health worker (nurse, medical assistant or doctor) would be trained to diagnose leprosy and manage the common complications, including reactions and neuritis. This person would also be trained to handle other health problems (either general, or perhaps another related field, such as dermatology or TB) . In Tanzania, these staff are trained for two years in dermatology, STD's and leprosy, as well as programme management. In some other countries in Africa, district TB/leprosy officers are trained for just 4-6 weeks.

Each country would have to determine who, where and for how long such staff would be trained.

Tertiary referral should be possible in every country, where all disabled people (including leprosy patients) can receive appropriate treatment.

　

P Saunderson, ALERT, Addis Ababa, ETHIOPIA

　

　

　

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