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Leprosy is a disease which has struck fear into human beings for thousands of years. This is partly because it causes considerable deformities and disabilities. In 1991, the 44th World Health Assembly adopted a resolution to eliminate the disease as a public health problem by the year 2000. However, one of the major obstacles to achieving this objective is the stigma associated with the disease. Stigma against leprosy patients affects all aspects of leprosy control. This paper describes a model of the stigmatization process in leprosy. The process of stigmatization can be divided into two stages. The first stage describes how certain cognitive dimensions of leprosy lead to a variety of affective responses towards the disease. The second stage involves how these affective responses contribute to social devaluation of the leprosy patient and consequently, the adoption of negative behaviours towards them.

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Improving immunization coverage is vital to promoting child health and reducing childhood diseases and deaths. In spite of being actively promoted as a major public health intervention for national development since the late 1970s, immunization coverage in Ghana remains low. We investigated factors that influence attendance to immunization sessions in the Komenda-Edina-Eguafo-Abrem District of Ghana. The major factors hindering attendance were poor knowledge about immunization, lack of suitable venues and furniture at outreach clinics, financial difficulties, long waiting times, transport difficulties, poorly motivated service providers and weak intersectoral collaboration. The timing of immunization sessions, length of prior notice to the community, attitude of service providers and fear of side-effects generally did not deter attendance.

PIP: Although childhood immunization has been a major national development goal in Ghana since the late 1970s, coverage rates remain low. In 1992, coverage for the third dose of diphtheria-pertussis-tetanus (DPT) was 43% for children under 12 months of age. The present study, conducted in August 1993, used focus group discussions and interviews with 469 mothers of children under 2 years of age, 17 service providers, and 10 heads of health-related sectors, to investigate factors influencing attendance to immunization sessions in Ghana's Komenda-Edina-Eguafo-Abrem District. 73% of mothers reported they attended child welfare clinics regularly. The main factors motivating mothers to attend were the perceived benefits of immunization for disease prevention, its impact on socioeconomic development, the relatively low cost of disease prevention, and the need for vaccination cards for school entry. The major factors hindering attendance were poor knowledge about immunization, lack of suitable venues and furniture at outreach clinics, financial difficulties, long waiting times, transportation problems, poorly motivated service providers, and weak intersectoral collaboration. The timing of immunization sessions, length of advance notice to the community, attitude of service providers, and fear of side effects generally did not deter attendance. Attention to the obstacles to compliance with childhood immunization schedules is essential if Ghana is to achieve the goal of 80% coverage by the year 2000.

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Integration of leprosy control into primary health care is the most comprehensive and permanent system of delivering care to leprosy patients. But so far only a few countries have adopted this approach, largely on account of a fear of failure. Over the past decade Ghana has developed a model approach towards the transition from a vertical to an integrated programme. The highlights of our approach included the development of the leprosy service as part of the overall development of the health service, increasing capacity building for leprosy control at the district and subdistrict levels as well as the establishment of a regular and effective monitoring to identify and correct operational problems early. This paper describes the principles behind the integration, the strategies adopted and how they were implemented. It also includes the achievements made as well as the problems that were encountered and how they were solved.

PIP: During the period from the late 1940s to the mid-1980s, the Ghana Leprosy Control Programme was a vertical program based out of Ankaful Leprosy Hospital. It has four other leprosy hospitals. The administrative and technical aspects of the program, once handled by the program's Senior Medical Officer, are now handled at the regional, district, and subdistrict levels. Headquarters' responsibilities now include development of national leprosy control policies, monitoring and evaluation of regional programs, technical advice and support, intermediary between the Ministry of Health (MOH) and donors, development of health education materials, and training of trainers in leprosy control. Events leading to integration of leprosy control into primary health care include: the 1978 Alma Ata Conference and resultant reorganization of the MOH; 1981 termination of training of specialized leprosy technical officers and training of multipurpose technical officers for epidemiology; and the economic crisis in the early 1980s. Since the mid-1980s, the MOH has introduced various initiatives to strengthen health care management at the district level (e.g., establishment of district health management teams). Once the MOH set the foundation for integration at the district level, in phases, it devolved the program's administrative functions to regions and some functions to district and subdistrict levels; prepared health care managers and providers for management of leprosy control within their regions; clarified roles of specialized leprosy technical officers vis-a-vis nonspecialized leprosy care providers; set up systematic monitoring and evaluation of programs at all levels; and strengthened the capacity of district hospitals to recognize and manage leprosy complications. Headquarters oversees the regions two times per year. The leprosy technical officer monitors each district four times per year. The district technical officer oversees each subdistrict once a month. Each level provides feedback. Donors were amenable to the transition's changing needs.

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