The experience gained by the integration of the leprosy eradication programme with the general health services has many lessons to offer in the context of the National Rural Health Mission's objective to combine the national health programmes for various diseases.
COMMENTARYapril 4, 2009 vol xliv no 14 EPW Economic & Political Weekly24terms. What about some plain old gender justice for a change? Starting with child-care leave for either parent?And why are men silently allowing themselves to be painted as unfeeling, heartless wretches who want to have nothing to do with their own children? It is not the women’s movement which is doing this male- bashing after all.So let us see this for what it is – a deadly mix of class and gender prejudice, and let all concerned with justice come together to continue the struggle – for maternity entitlements forallwomen, in all sectors, starting with poor women in the un-organised sector; for crèches at all levels for women struggling withmultiple burdens, starting with the Integrated Child Development Scheme; and for op-portunity for men to prove that they are not child haters.Lessons for Integration of Health ProgrammesMathew GeorgeMathew George (matsajo@gmail.com) is at the School of Health Systems Studies, Tata Institute of Social Sciences, Mumbai.The experience gained by the integration of the leprosy eradication programme with the general health services has many lessons to offer in the context of the National Rural Health Mission’s objective to combine the national health programmes for various diseases.The programme for leprosy control in the country started in 1955. How-ever, recent developments in the programme call for a critical analysis. The initiative to integrate leprosy control activities with general health services gained momentum with the popularisation of the National Rural Health Mission (NRHM). With the introduction of multidrug therapy (MDT) in 1983, the programme was re-named as an initiative to eradicate the dis-ease completely by 2000 (Pandey et al 2006). Elimination of a disease is defined as the stage when its prevalence reaches less than 1 per 10,000 populations. A significant decline in the number of cases has been re-ported since then. In 2001 the second phase of the National Leprosy Eradication Pro-gramme (NLEP) started with the objective of decentralising its activities and which ulti-mately initiated the process of integration with the general health services (ibid). The need to integrate various disease control programmes with the general health servic-es has been voiced from various quarters for more than three decades now. It is impor-tant to learn from the experience of leprosy control in the current context when one of the major objectives of the NRHM is to inte-grate various national health programmes with the general health services. The current article is an attempt to examine the issues and challenges involved in such integration in the context of the leprosy control activi-ties and the NRHM.Evolution of the ProgrammeThe leprosy control programme was cen-trally aided and its pace was slow until the introduction of MDT in 1983. The strategy then was based on the endemicity of the cases with vertical structures like survey education and treatment centres, leprosy control units and urban leprosy centres. In each of these, paramedical workers were given the primary responsibility of sur-veillance (active) carried out through house-to-house visits. The strategy for case identification was survey, education and treatment (SET) that involved identifi-cation of the cases from the field, provid-ing awareness of the disease to those affected and making sure that they con-tinued the treatment (Banerji 1985: 118). The non-governmental organisations (NGOs) have also been playing a vital role all through the history of leprosy control in the country. Around 290 voluntary organ-isations are presently actively engaged in leprosy relief services with 127 of them involved inSET activities and of which 50 are covered by the SET grant from the government of India.1 Earlier, theNGOs were involved in almost all aspects like case detection, treatment, public aware-ness creation, training, disability preven-tion and so on. Once the programme took off, only those areas where the govern-ment was not able to provide services were covered by these NGOs, thus keeping their role to a minimum. Despite this, the con-tribution of the NGOs must be acknowl-edged for its strong component of training rooted in experience and an efficient system for disability prevention (Lockwood and Suneetha 2005). Three is thus a need to redefine and situate the role of NGOs in the programme after integration.Integration: Some Concerns Integration implies that leprosy control activities become the responsibility of the general health services as part of routine day-to-day activities. Integration was influ-encedby the international acceptance of primary healthcare approach, the World
COMMENTARYEconomic & Political Weekly EPW april 4, 2009 vol xliv no 1425Health Organisations (WHO) campaign for elimination and more importantly the introduction of MDT (Feenstra and Viss-chedijk 2002). Thus equity and sustaina-bility, the major components of primary healthcare approach also became the major justification for integration. Equity implies comprehensive care as well as care-specific to leprosy patients. This is in contrast to the vertical services that are provided otherwise on specific days and separately for leprosy patients. Here the challenge is to ensure quality and specialised services to those affected with leprosy but as a responsibility of the general health services. Second, the question of sustaina-bility gains prominence as the reliability and support towards general health services is higher than towards those services provided by a vertical setting. Moreover, integration expects to improve access to leprosy control services through which it reduces stigma and the gender bias at-tached to it. The experiences with integra-tion of leprosy control services in various countries reveal a mixed trend. The positive element identified by some countries was the decentralised, health services system that could address the uneven distribution of leprosy cases whereas inadequacy in planning the integration process was identified as a major shortcoming; parti-cularly the processes of training and monitoring (ibid). Uneven DistributionPrior to the introduction of MDT, leprosy was found more among the southern states of the country. According to a recent report, however, the burden is more among states like Bihar, Jharkhand, Chhattisgarh, Uttar Pradesh and West Bengal (Joshi et al 2007). This could be due to the improved surveillance mechanism prevalent now in these states as compared to earlier times. As per 2006 estimates, around 50% of new cases of leprosy detected worldwide were from India, and of these two-thirds were confined to the above mentioned five states (ibid). Bihar, Chandigarh, Chhattis-garh,Delhiand Jharkhand have a preva-lenceratebetween 1 and 2 per 10,000 populations while in Dadra and Nagar Haveli the rate is 2.11 per 10,000 popula-tions. These together contribute to 25% of the country’s recorded caseload (ibid). Reports also indicate that there has been a drastic decline in prevalence rate due to the introduction of MDT for leprosy. Scholars have been sceptical about us-ing prevalence rate as an indicator for the magnitude of the problem and there is a controversy over whether elimination is a virtual phenomenon or a reality (Lockwood 2002). The decline is attributed to the re-duction in the treatment period with the new regime, when prevalence is calculated on the basis of those who take treatment. This is only reported prevalence (iceberg) submerging the real prevalence. The two major indicators that reveal the burden of leprosy, namely, case detection rate and reported prevalence are predominantly dependent on the surveillance mechanism prevalent and treatment regimen followed as well as the access to treatment. This being the case, the burden of leprosy cases can appear to decline if there is a failure in the mechanism for diagnosis and treat-ment. This was the situation in India when the case detection rates became stagnant with high rates among children (about 17%), an indication of the fact that leprosy is being transmitted in the community (Lockwood and Suneetha 2005). More-over when disability due to leprosy is on the increase, it indicates that the disease is spreading. Thus, any approach to control leprosy must put a system in place that can ensure prevention of the disease at the primary, secondary and tertiary levels of prevention. These in the context of leprosy can be active surveillance for new cases, effective provisioning of treatment to the patient as near to his/her home as possible with an equally vigorous mechanism to follow-up cases to ensure patient adherence and, last but not the least, prevention of disability and rehabilitation. It is in this context that the call to integrate all na-tionalhealth programmes becomes relevant both as an opportunity as well as a chal-lenge since any programme once integrat-ed will “sink” or “sail” with the general health services (Banerji 2005). Possibilities within NRHMTheNRHM acknowledges the need to inte-grate health programmes since it recog-nises limited synergism of disease control activities at the operational level. It further calls for decentralised services that give ample scope to address the regional in-equalities that are relevant as far as the problem of leprosy is concerned. Besides, the overall strengthening and effectiveness of general health institutions, the major focus ofNRHM, has positive consequences for the leprosy control programme as it is already integrated. The Common Review Mission of NRHM aims to build in thepre-ventive, promotive and curative carefor communicable diseases into the definition of fully functional health facilities thereby providing for promotive and preventive services within the general health services (GoI 2007). This is accomplished by deve-loping standard treatment guidelines, essential drug lists, referral systems, support systems for capacity building, logistics, and monitoring, and behaviour change communication (BCC) interventions. This, along with the bringing together of district health societies of tuberculosis, malaria and leprosy under state health societies is already in the process (Pandey et al 2006). In order to ensure horizontal integration sharing of laboratory infrastructure, equip-ment and technicians amongst various control programmes has been recom-mended. Developing multiple skills is rec-ommended by NRHM for pharmacists, lab-oratory technician and other support staff. The mission also guarantees full coverage of curative and restorative services related to leprosy. In addition to these the mission also offers space for NGOs/civil society or-ganisations especially in the field of train-ing, monitoring and evaluation.NLEP within NRHMThus in the current scenario integration provides a new outlook when seen through the lens of theNRHM. Its approach on inte-gration of leprosy control activities appears to be to provide Accredited Social Health Activists (ASHAs), the central component of NRHM, the major responsibility for case detection of leprosy. The central role of case detection/surveillance both in terms of administrative and technical competence, in effective implementation of leprosy control programme has been identified by many scholars earlier (Lockwood and Suneetha 2005). Here the context in which ASHAs work becomes crucial as incentivi-sation (cash) of their work and its set-backs in Reproductive and Child Health
COMMENTARYapril 4, 2009 vol xliv no 14 EPW Economic & Political Weekly24terms. What about some plain old gender justice for a change? Starting with child-care leave for either parent?And why are men silently allowing themselves to be painted as unfeeling, heartless wretches who want to have nothing to do with their own children? It is not the women’s movement which is doing this male- bashing after all.So let us see this for what it is – a deadly mix of class and gender prejudice, and let all concerned with justice come together to continue the struggle – for maternity entitlements forallwomen, in all sectors, starting with poor women in the un-organised sector; for crèches at all levels for women struggling withmultiple burdens, starting with the Integrated Child Development Scheme; and for op-portunity for men to prove that they are not child haters.Lessons for Integration of Health ProgrammesMathew GeorgeMathew George (matsajo@gmail.com) is at the School of Health Systems Studies, Tata Institute of Social Sciences, Mumbai.The experience gained by the integration of the leprosy eradication programme with the general health services has many lessons to offer in the context of the National Rural Health Mission’s objective to combine the national health programmes for various diseases.The programme for leprosy control in the country started in 1955. How-ever, recent developments in the programme call for a critical analysis. The initiative to integrate leprosy control activities with general health services gained momentum with the popularisation of the National Rural Health Mission (NRHM). With the introduction of multidrug therapy (MDT) in 1983, the programme was re-named as an initiative to eradicate the dis-ease completely by 2000 (Pandey et al 2006). Elimination of a disease is defined as the stage when its prevalence reaches less than 1 per 10,000 populations. A significant decline in the number of cases has been re-ported since then. In 2001 the second phase of the National Leprosy Eradication Pro-gramme (NLEP) started with the objective of decentralising its activities and which ulti-mately initiated the process of integration with the general health services (ibid). The need to integrate various disease control programmes with the general health servic-es has been voiced from various quarters for more than three decades now. It is impor-tant to learn from the experience of leprosy control in the current context when one of the major objectives of the NRHM is to inte-grate various national health programmes with the general health services. The current article is an attempt to examine the issues and challenges involved in such integration in the context of the leprosy control activi-ties and the NRHM.Evolution of the ProgrammeThe leprosy control programme was cen-trally aided and its pace was slow until the introduction of MDT in 1983. The strategy then was based on the endemicity of the cases with vertical structures like survey education and treatment centres, leprosy control units and urban leprosy centres. In each of these, paramedical workers were given the primary responsibility of sur-veillance (active) carried out through house-to-house visits. The strategy for case identification was survey, education and treatment (SET) that involved identifi-cation of the cases from the field, provid-ing awareness of the disease to those affected and making sure that they con-tinued the treatment (Banerji 1985: 118). The non-governmental organisations (NGOs) have also been playing a vital role all through the history of leprosy control in the country. Around 290 voluntary organ-isations are presently actively engaged in leprosy relief services with 127 of them involved inSET activities and of which 50 are covered by the SET grant from the government of India.1 Earlier, theNGOs were involved in almost all aspects like case detection, treatment, public aware-ness creation, training, disability preven-tion and so on. Once the programme took off, only those areas where the govern-ment was not able to provide services were covered by these NGOs, thus keeping their role to a minimum. Despite this, the con-tribution of the NGOs must be acknowl-edged for its strong component of training rooted in experience and an efficient system for disability prevention (Lockwood and Suneetha 2005). Three is thus a need to redefine and situate the role of NGOs in the programme after integration.Integration: Some Concerns Integration implies that leprosy control activities become the responsibility of the general health services as part of routine day-to-day activities. Integration was influ-encedby the international acceptance of primary healthcare approach, the World 
COMMENTARYEconomic & Political Weekly EPW april 4, 2009 vol xliv no 1425Health Organisations (WHO) campaign for elimination and more importantly the introduction of MDT (Feenstra and Viss-chedijk 2002). Thus equity and sustaina-bility, the major components of primary healthcare approach also became the major justification for integration. Equity implies comprehensive care as well as care-specific to leprosy patients. This is in contrast to the vertical services that are provided otherwise on specific days and separately for leprosy patients. Here the challenge is to ensure quality and specialised services to those affected with leprosy but as a responsibility of the general health services. Second, the question of sustaina-bility gains prominence as the reliability and support towards general health services is higher than towards those services provided by a vertical setting. Moreover, integration expects to improve access to leprosy control services through which it reduces stigma and the gender bias at-tached to it. The experiences with integra-tion of leprosy control services in various countries reveal a mixed trend. The positive element identified by some countries was the decentralised, health services system that could address the uneven distribution of leprosy cases whereas inadequacy in planning the integration process was identified as a major shortcoming; parti-cularly the processes of training and monitoring (ibid). Uneven DistributionPrior to the introduction of MDT, leprosy was found more among the southern states of the country. According to a recent report, however, the burden is more among states like Bihar, Jharkhand, Chhattisgarh, Uttar Pradesh and West Bengal (Joshi et al 2007). This could be due to the improved surveillance mechanism prevalent now in these states as compared to earlier times. As per 2006 estimates, around 50% of new cases of leprosy detected worldwide were from India, and of these two-thirds were confined to the above mentioned five states (ibid). Bihar, Chandigarh, Chhattis-garh,Delhiand Jharkhand have a preva-lenceratebetween 1 and 2 per 10,000 populations while in Dadra and Nagar Haveli the rate is 2.11 per 10,000 popula-tions. These together contribute to 25% of the country’s recorded caseload (ibid). Reports also indicate that there has been a drastic decline in prevalence rate due to the introduction of MDT for leprosy. Scholars have been sceptical about us-ing prevalence rate as an indicator for the magnitude of the problem and there is a controversy over whether elimination is a virtual phenomenon or a reality (Lockwood 2002). The decline is attributed to the re-duction in the treatment period with the new regime, when prevalence is calculated on the basis of those who take treatment. This is only reported prevalence (iceberg) submerging the real prevalence. The two major indicators that reveal the burden of leprosy, namely, case detection rate and reported prevalence are predominantly dependent on the surveillance mechanism prevalent and treatment regimen followed as well as the access to treatment. This being the case, the burden of leprosy cases can appear to decline if there is a failure in the mechanism for diagnosis and treat-ment. This was the situation in India when the case detection rates became stagnant with high rates among children (about 17%), an indication of the fact that leprosy is being transmitted in the community (Lockwood and Suneetha 2005). More-over when disability due to leprosy is on the increase, it indicates that the disease is spreading. Thus, any approach to control leprosy must put a system in place that can ensure prevention of the disease at the primary, secondary and tertiary levels of prevention. These in the context of leprosy can be active surveillance for new cases, effective provisioning of treatment to the patient as near to his/her home as possible with an equally vigorous mechanism to follow-up cases to ensure patient adherence and, last but not the least, prevention of disability and rehabilitation. It is in this context that the call to integrate all na-tionalhealth programmes becomes relevant both as an opportunity as well as a chal-lenge since any programme once integrat-ed will “sink” or “sail” with the general health services (Banerji 2005). Possibilities within NRHMTheNRHM acknowledges the need to inte-grate health programmes since it recog-nises limited synergism of disease control activities at the operational level. It further calls for decentralised services that give ample scope to address the regional in-equalities that are relevant as far as the problem of leprosy is concerned. Besides, the overall strengthening and effectiveness of general health institutions, the major focus ofNRHM, has positive consequences for the leprosy control programme as it is already integrated. The Common Review Mission of NRHM aims to build in thepre-ventive, promotive and curative carefor communicable diseases into the definition of fully functional health facilities thereby providing for promotive and preventive services within the general health services (GoI 2007). This is accomplished by deve-loping standard treatment guidelines, essential drug lists, referral systems, support systems for capacity building, logistics, and monitoring, and behaviour change communication (BCC) interventions. This, along with the bringing together of district health societies of tuberculosis, malaria and leprosy under state health societies is already in the process (Pandey et al 2006). In order to ensure horizontal integration sharing of laboratory infrastructure, equip-ment and technicians amongst various control programmes has been recom-mended. Developing multiple skills is rec-ommended by NRHM for pharmacists, lab-oratory technician and other support staff. The mission also guarantees full coverage of curative and restorative services related to leprosy. In addition to these the mission also offers space for NGOs/civil society or-ganisations especially in the field of train-ing, monitoring and evaluation.NLEP within NRHMThus in the current scenario integration provides a new outlook when seen through the lens of theNRHM. Its approach on inte-gration of leprosy control activities appears to be to provide Accredited Social Health Activists (ASHAs), the central component of NRHM, the major responsibility for case detection of leprosy. The central role of case detection/surveillance both in terms of administrative and technical competence, in effective implementation of leprosy control programme has been identified by many scholars earlier (Lockwood and Suneetha 2005). Here the context in which ASHAs work becomes crucial as incentivi-sation (cash) of their work and its set-backs in Reproductive and Child Health 
