India is home to roughly two thirds of the registered cases in the world. And the effectiveness of tackling leprosy in India will determine theleprosy situation globally.

Fortunately leprosy has always been high on the political agenda of India. This has been translated into concrete steps with the creation of the National Leprosy Eradication Programme (NLEP) almost two decades ago. Significant progress has been made since: 10 million patients of the 12 million patients cured globally are from India. The prevalence rate has declined dramatically from 57 per 10,000 inhabitants to the current level of 4.2 per 10,000. Admittedly the greatest decline was in the first five years after introducing MDT and discharging the large numbers of inactive cases from the registers. Nonetheless the numbers are truly impressive: the registered prevalence has come down from 3.4 million patients in 1986 to 433,000 in 2002!!!

Despite the tremendous achievements, we need to ask ourselves a critical question. Given the resources invested in the past-and which are currently being invested-could we have done better? Can we do better? Are we really addressing the problems that have been identified-fundamental problems such as limited geographical coverage, limited community involvement, over diagnosis, poor treatment completion rates? Is the emphasis on doing more of the same instead of implementing corrective measures, which are urgently needed in order to achieve the elimination goal?

　

A question which we as "outsiders" must ask ourselves-and answer honestly is-are the day to day activities that we support in line with the letter and spirit of the government's plan? Or are we undermining efforts in the field by not completely following the government's guidelines and norms? How can we best support the Government of India to eliminate leprosy?

　

Let me share with you a summary of our analysis of the current situation and obstacles. I will be brief but will distribute a more complete document for you to look at later. My comments are based largely on the evaluation carried out by the Government of India, WHO and the World Bank and which formed the basis of the current plan of action.

　

The key challenge facing the Government of India, and us, is how can we improve patients' access to leprosy treatment as well as create an environment in which people do not hesitate to seek treatment.

　

Despite endorsement that integration is the best way to improve the geographical coverage of leprosy services and help to ensure that the future cases will be taken care of, even after "elimination", implementation has not been straightforward. Transforming NLEP from a vertical program into an integrated one created challenges on every level-administrative, technical, human, with shifts of power and resources, changing roles and authority. Managing this complex process and keeping it on track requires diverse unique skills, which are not easy to find.

　

NLEP was directed from the Central level with the advantage of clear lines of authority and direction-but the serious disadvantage that there was little/no involvement of the states and local health authorities in leprosy elimination activities. The shift of power from the central level to the states authorities is now a reality in all the states. However putting into place the technical norms and building the necessary skills and teams at a local level has required more time than originally envisaged. Efforts are also being undermined in the filed: Leprosy workers virtually opposed integration, as many privileges would be revoked. Sometimes we only give lip service support to integration and continue to put resources into maintaining vertical structures.

　

New innovative approaches need to be found to motivate health workers. The continued reliance on target setting and achieving these targets often distorts the real picture of leprosy in the filed.

All of us working in leprosy are spoiled-we have the luxury of resources with little need to question the cost effectiveness of our efforts. There is an urgent need to change this. We must develop a framework to define what is an acceptable cost-eftectiveness return in terms of patients reached/cured. Clearly the costs of operating in difficult to reach areas will be higher than others. We must critically review the way we work and how we deploy our resources and look for ways to improve the effectiveness of our spending.

India has been a trend setter in changing the negative image of leprosy. The recent initiative to involve Bollywood is simply extraordinary. Moving Bollywood for leprosy will really change the image of the disease. And the spots are fantastic. I would like to compliment and congratulate the Government of India on this brilliant move.

　

But on a more critical note, is the rolling out of these spots and those developed with the BBC support within the framework of a comprehensive communications campaign? Are we monitoring the impact? Are we sure that MDT is available in all health centers or are we creating expectations that we cannot meet? It is also crucial that all organizations working in leprosy do not undermine this "positive" approach for fund raising purposes.

Training of health workers to diagnose and treat leprosy often seems to me like a bottomless black box which absorbs disproportionate amount of resources with often questionable results. Yet it should be relatively easy to train people in leprosy. We are in an exceptional situation in which no diagnostic tools are needed, classification is simple, and treatment regimens are standardized and easy to deliver in the field. And above all they are highly effective and safe!

　

An area, which remains neglected, is the retraining of the vertical staff to permit their reallocation for other diseases. Understandably it can be a very difficult situation for those concerned. But it is our responsibility to address the administrative and legal issues related to this and provide them with the necessary skills so that they can be gainfully employed for another disease.

This will become increasingly critical to better understand the local leprosy situation and better target control activities as the overall number of cases comes down and at the same time, there is a concentration of cases in clusters. In addition, the ownership for disease surveillance is already with the states and it is important that they take on ownership for leprosy too.

Partners-both national and international-are highly active in leprosy and have an important role to play. However their activities must be within the framework and technical norms set by the Government of India. Deviations from this are simply unacceptable and cause confusion in the field.

　

Today, leprosy elimination in India is at a critical juncture. Although resources are available, implementation of the national elimination plan requires commitment, improved management at central and state levels and clear definition of the role of staff notably the vertical one. Coordination of the implementation of key activities as well as the input of all contributing agencies is the main challenge for GOI.

　

In conclusion, I remain convinced that we are on the right track. The Government of India has taken decisive action to create a framework in order to implement the key tasks. And the task ahead is to support the implementation of the national plan, on the necessary scale. And, above all let us remember as we continue with our deliberations and more importantly with our work in the field-that the ownership for leprosy elimination is with the Government of India. We must work within the framework that they define.

　

Finally, let me quote Dr. Gro Harlem Brundtland, Director General of WHO, in the speech she delivered two weeks ago at the World Health Assembly: 'WHO provides an umbrella of authoritative positions under which many others can act for health. This includes confronting all forms of and discrimination in relation to leprosy or other stigmatizing conditions." On be half of WHO, I can assure you that our commitment to eliminate the disease and dispel the fears and stigma surrounding it remain high and cannot be compromised.