Health reform: special report. Health reform turns two: after passage of the Affordable Care Act, the work--and the criticisms--persist.

UNLABELLED: NCSL tracks state actions on federal health reform closely. You can learn more about federal regulations, state legislation, Medicaid, insurance reform and more at www.ncsl.org/healthreform. Several NCSL health staff contributed to this package of stories related to the two-year anniversary of the Affordable Care Act. Contributors: Exchanges: job no. 1--Martha Salazar. Big changes for insurers--Richard Cauchi. Sharp divisions persist over law's future--Richard Cauchi. Transforming Medicaid--Melissa Hansen. States decided essential benefits--Richard Cauchi. PREVENTION: more than an ounce--Amy Winerfeld. Help wanted: doctors and nurses--Laura Tobler.

Cost-effectiveness of interventions to prevent disability in leprosy: a systematic review.

BACKGROUND: Prevention of disability (POD) is one of the key objectives of leprosy programmes. Recently, coverage and access have been identified as the priority issues in POD. Assessing the cost-effectiveness of POD interventions is highly relevant to understanding the barriers and opportunities to achieving universal coverage and access with limited resources. The purpose of this study was to systematically review the quality of existing cost-effectiveness evidence and discuss implications for future research and strategies to prevent disability in leprosy and other disabling conditions. METHODOLOGY/PRINCIPAL FINDINGS: We searched electronic databases (NHS EED, MEDLINE, EMBASE, and LILACS) and databases of ongoing trials (www.controlled-trials.com/mrct/, www.who.int/trialsearch). We checked reference lists and contacted experts for further relevant studies. We included studies that reported both cost and effectiveness outcomes of two or more alternative interventions to prevent disability in leprosy. We assessed the quality of the identified studies using a standard checklist for critical appraisal of economic evaluations of health care programmes. We found 66 citations to potentially relevant studies and three met our criteria. Two were randomised controlled trials (footwear, management of neuritis) and one was a generic model-based study (cost per DALY). Generally, the studies were small in size, reported inadequately all relevant costs, uncertainties in estimates, and issues of concern and were based on limited data sources. No cost-effectiveness data on self-care, which is a key strategy in POD, was found. CONCLUSION/SIGNIFICANCE: Evidence for cost-effectiveness of POD interventions for leprosy is scarce. High quality research is needed to identify POD interventions that offer value for money where resources are very scarce, and to develop strategies aimed at available, affordable and sustainable quality POD services for leprosy. The findings are relevant for other chronically disabling conditions, such as lymphatic filariasis, Buruli ulcer and diabetes in developing countries.

Formas de aislamiento físico y simbólico: la lepra, sus espacios de reclusión y el discurso médico-legal en Argentina / Ways of physical and symbolic isolation: leprosy, its isolation spaces and the medical-legal discourse in Argentina

Durante la primera mitad del siglo XX la presencia de la lepra en sociedades modernas suscitó variadas reacciones. Aun sin que desaparecieran ancestrales prejuicios, el discurso médico-legal abordó un problema que excedía el marco estrictamente sanitario. El trabajo analiza el modo en que, desde una perspectiva científica, fueron gestadas en Argentina respuestas que creyeron hallar en el aislamiento físico y simbólico del leproso una forma proteger la población y el futuro de la raza. En ese contexto, la eugenesia legitimó fuertes restricciones de derechos a enfermos sobre los que siguió pesando aquel estigma ancestral (AU)

During the first half of the twentieth century, the presence of leprosy in modern societies provoked various reactions. As ancient prejudices had not disappeared yet, the medical-legal discourse dealt with a problem that exceeded the strictly sanitary framework. From a scientific perspective, this paper analyzes the way in which answers find that seemed the population and the future of the race in the physical and symbolic isolation of the leper, were developed in Argentina. In that context, the eugenics legitimated strong restrictions of rights to sick persons on whom this ancestral stigma continued to carry much weight (AU)

[Ways of physical and symbolic isolation: leprosy, its isolation spaces and the medical-legal discourse in Argentina]. / Formas de aislamiento físico y simbólico: la lepra, sus espacios de reclusión y el discurso médico-legal en Argentina.

During the first half of the twentieth century, the presence of leprosy in modern societies provoked various reactions. As ancient prejudices had not disappeared yet, the medical-legal discourse dealt with a problem that exceeded the strictly sanitary framework. From a scientific perspective, this paper analyzes the way in which answers find that seemed the population and the future of the race in the physical and symbolic isolation of the leper, were developed in Argentina. In that context, the eugenics legitimated strong restrictions of rights to sick persons on whom this ancestral stigma continued to carry much weight.

Global strategy for further reducing the leprosy burden and sustaining leprosy control activities 2006-2010. Operational guidelines.

The Global Strategy for further reducing the leprosy burden and sustaining leprosy control activities (2006 - 2010) has been widely welcomed and endorsed. The overall goal is to provide access to quality leprosy services for all affected communities following the principles of equity and social justice. The purpose of these Operational Guidelines is to help managers of national health services to implement the new Global Strategy in their own countries. This will be done as they develop detailed policies applicable to their own situation, and revise their National Manual for Leprosy Control. Leprosy services are being integrated into the general health services throughout the world; a new emphasis is given here to the need for an effective referral system, as part of an integrated programme. Good communication between all involved in the management of a person with leprosy or leprosy- related complications is essential. These Guidelines should help managers to choose which activities can be carried out at the primary health care level and for which aspects of care patients will have to be referred. This will depend on the nature of the complication and the capacity of the health workers to provide appropriate care at different levels of the health system. The promotion of self-reporting is now crucial to case detection, as case- finding campaigns become less and less cost-effective. It is important to identify and remove barriers that may prevent new cases from coming forward. The procedures for establishing the diagnosis of leprosy remain firmly linked to the cardinal signs of the disease, but the accuracy of diagnosis must be monitored. The Guidelines suggest a greater emphasis on the assessment of disability at diagnosis, so that those at particular risk can be recognized and managed appropriately. The treatment of leprosy with MDT has been a continuing success; neither relapse nor drug-resistance are significant problems and the regimens are well- tolerated. Clear procedures are given for managing irregular treatment with MDT. Leprosy reactions are a serious complication affecting some patients. The Guidelines contains this aspect, with additional references under Further Reading. A key decision for programme managers is to determine how and at which level of the health system leprosy reactions are to be managed in their country. Different countries must develop their own detailed guidelines on this issue. Prevention of disability (POD) is also described in some detail as there is a need for much greater coverage with basic POD activities. This is an important component of 'quality leprosy services' emphasized in the Global Strategy. Items mentioned under Further Reading will be essential for programmes planning to build capacity and increase their service provision in this area. Rehabilitation may include a medical component (such as reconstructive surgery) but its scope is much broader. It is likely that some people affected by leprosy would benefit from socio-economic rehabilitation (for example, vocational training or a small loan). Staff in the health services need to be familiar with what is being done in the locality, and know how and where to refer people who need these services. Recording and reporting are essential to maintain quality in any programme. The indicators selected in the Global Strategy are useful for monitoring and evaluation, and they determine which data must be recorded. The data needed to monitor POD activities have not been collected routinely in the past, so this represents a significant change - national managers must therefore decide for themselves which indicators will be used to ensure quality as these will vary from country to country. Programme management is a broad subject; the topics covered in this Section are those that are central to the running of integrated leprosy control services, including supervision, supply of MDT, partnerships, training and programme evaluation.

Management of HIV in resource-poor countries, with a focus on sub-Saharan Africa.

HIV/AIDS is the modern world's greatest pandemic, the brunt of which falls on sub-Saharan Africa. HIV/AIDS control efforts have up till now focused mainly on prevention, with little attention paid to care. This approach must change, and prevention has to be linked with an essential package of care if there is to be any hope of reducing HIV incidence rates or curbing the morbidity and mortality associated with AIDS. The package of care includes psycho-social support, screening for sexually transmitted infections and tuberculosis, clinical care for opportunistic infections, palliative care for terminal illness, home based care, care and support for orphans, prevention of mother to child transmission of HIV, preventive therapy and the possibility of antiretroviral (ARV) drugs. Many countries in sub-Saharan Africa are developing plans to scale-up treatment and prevention programmes, including the use of ARV drugs. However, any meaningful challenge to the AIDS epidemic requires a huge scale-up of support from the international community, both for ARV drugs and for basic prevention and care packages.

[Estimation of the impact of the principal diseases in rural Mali]. / Estimation de l'impact des principales maladies en zone rurale malienne.

The authors assess the health impact of major diseases in the circles of Kita, Bafoulabé and Kenieba (Western Mali) by measuring, for each of them, the number of healthy days of life lost through illness, disability and death. Malaria, birth diseases, infant gastro-enteritis and pneumopathies, measles, malnutrition and hemoglobinopathies account for 58.1% of healthy life lost due to all studied diseases. Parasitic diseases (except malaria), tuberculosis, leprosy are less important than usually said; on the contrary, the impact of hepatic, cardiovascular, and eyes diseases is great. In developing countries assessing the number of healthy days lost by the community due to different diseases is usefull to choose the health priorities and to compare the cost/effectiveness ratio of different health programs.