Sustaining leprosy services in the changing context of health sector reform

National leprosy control programmes currently face a number of changes to the environment within which they operate. This paper examines the issues arising from these. It focuses, in particular, on those arising from changes in the structure of the health sector as a result of policies of health sector reform which are being considered or adopted in many developing countries. These include decentralization, financing strategies, greater role for the private and NGO sectors and the integration of vertical programmes. The paper is structured around a number of key steps in the development of a strategy for sustainability of appropriate leprosy services. These are the assessment of the epidemiological, social and health services context, development of programme objectives, planning of human and financial resources, development of the strategy, mapping the roles of potential actors, development of regulatory and incentive mechanism, action planning and managing change and, finally, re-evaluation of the programme objectives and service delivery organization. The paper stresses the importance of process in developing ownership of a strategy. It concludes with a set of key questions which it suggests need to be addressed by leprosy programme managers in the development of a proactive response to the changes.