When working towards sustainable services, a critical review of essential required skills at all levels is important Often, the leprosy tasks should be only a small part of the tasks of a health worker. He or she will be responsible for solving many other health problems.
2.2.3 Standardisation of tasks
Diagnostic tasks need to be standardised. I'll give you an example outside the leprosy field： The recent WHO-initiative on the Integrated Management of Child Diseases seems to be a successful approach. This initiative trains health workers to assess an ill child systematically and provide comprehensive treatment according to strict protocols.
I think it is useful to consider its equivalent solution： the integrated management of skin diseases? Could simple, but valid algorithms on diagnosis and management of skin lesions help the peripheral health worker to come to meaningful decisions and actions? I think it is time to explore this method.
2.2.4 Patient organisations
Promotion of patient organisations, capable of pressurizing governments to fulfill their responsibilities, for me is an important activity to try to increase political commitment of governments. Experiences in a few countries (among others in Brazil) are promising. A lot more can be done to increase the power of these types of movements.
3. Shaping the future
3.1 Models
There is an urgent need to develop models for leprosy control in low prevalence areas. Flexible and adaptable models, no doubt, but models nevertheless, designed, tested and marketed.
Two aspects of a possible model are worth mentioning here： towards further integration of management tasks and the development of an outbreak management model.
3.1.1 Towards integrated management and support tasks
An important part of the attempt to increase efficiency is the integration of the various required tasks. Multipurpose clinics and staff would attend to all curative and preventive needs of leprosy patients. Management, supervision, training, all these tasks could be done by the general health services, provided sufficient attention to the needs of the leprosy control programme will be given.
When leprosy control activities are partly integrated, the combination of leprosy control and other chronic disease control like tuberculosis control are possibilities to improve cost-effectiveness of both programmes. (but not guaranteed!)
3.1.2 Contraction of clinical services
With the declining prevalence, a phenomenon called contraction of leprosy patient services is likely to happen： With contraction I mean a change in definition of functions of health institutions, towards：
･ Centralisation of the diagnosis and treatment function.
･ Maintenance of a sufficient level of awareness among the population and peripheral health staff; these staff should be able to suspect and refer.
3.1.3 Outbreak management
This contraction and the existence of centrally located permanent staff knowledgeable on leprosy control, may lead to a different response in case of the discovery of a new case of leprosy after some time of zero diagnosis.
