Program Performance Indicators Research Articles

The implementation of an organised cervical screening programme in Poland: an analysis of the adherence to European guidelines.

BackgroundWell-organised quality-controlled screening can substantially reduce the burden of cervical cancer (CC). European guidelines (EuG) for quality assurance in CC screening provide guidance on all aspects of an organised screening programme. Organised CC screening in Poland was introduced in 2007. The purpose of our study was to analyse: (i) adherence of the programme to EuG; (ii) programme process and performance indicators; (iii) impact of the programme on the incidence of and mortality from CC.MethodsAvailable data on the policy, structure and functioning of the Polish programme were compared with the major points of the EuG. Data on the process, and available performance indicators were drawn from the screening database and other National Health Fund (NHF) systems. Joinpoint regression was used to assess changes in CC incidence and mortality trends.ResultsThe Polish programme adheres partially to EuG in terms of policy and organisation. Only a limited set of performance indicators can be calculated due to screening database incompleteness or lack of linkage between existing databases. The screening database does not include opportunistic smears collected within NHF-reimbursed or private care. The organised programme coverage rate fluctuated from 21% to 27% between 2007-2013. In 2012 the coverage reached 35% after combining both organised and opportunistic smears reimbursed by the NHF. In 2012 the number of smears reimbursed by NHF was 60% higher in opportunistic than in organised screening with significant overlap. Data from the private sector are not recorded. Depending on years, 30-50% of women referred for colposcopy/biopsy because of abnormal Pap smears were managed within the programme. The age-standardised CC incidence and mortality dropped linearly between 1999 and 2011 without evidence of a period effect.ConclusionsThe Polish organised cervical screening programme is only partially adherent to evidence-based EuG. Its implementation has not influenced the burden of CC in the country so far. Changes with special focus on increasing coverage, development of information systems and assessment of quality are required to increase programme adherence to EuG and to measure its effectiveness. Our findings may be useful to improve the Polish programme and those implemented or planned in other countries.Electronic supplementary materialThe online version of this article (doi:10.1186/s12885-015-1242-9) contains supplementary material, which is available to authorized users.

Characteristics and effectiveness of university spin‐off support programmes

Purpose The purpose of this paper is to identify different program models supporting the creation of spin‐offs at universities, analyzes the characteristics that differentiate them, and identifies the factors that determine their effectiveness. Design/methodology/approach The analysis was performed using data collected through a survey targeting the heads of spin‐off support programs at universities in the UK and Spain. The authors then applied factorial and cluster analysis techniques and a logistic regression analysis to the data to confirm the results. Findings The analysis identified three types of spin‐off support programs in these universities. Among these, the authors found one that appears to be the most effective model. The authors also found a certain “country effect” on the characteristics of the most effective model. Finally, the authors noted the importance the literature places on university R&D activity and the existence of a favorable environment for the performance of spin‐off programs. Research limitations/implications This research is limited by the use of number of spin‐offs and survival rate as performance indicators for support programs. Future research should consider the effective contributions to economic growth and the extent to which such effects are related to university‐level policies. Practical implications The typology of the spin‐off support programs identified here provides insight for recommendations to improve less‐effective models. Originality/value This study contributes to the understanding of the role of university policy measures in spin‐off support program effectiveness, and of how the environment influences these policies.

Immunization Coverage in WHO Regions: A Review Article

In 1974, the World Health Organization (WHO) established the Expanded Program on Immunization (EPI) to ensure that all children have access to routinely recommended vaccines. Since then, global coverage with the four core vaccines (Bacille calmette guerin vaccine [for protection against tuberculosis], Diphtheria-tetanus-pertussis vaccine [DTP], Polio vaccine, and Measles vaccine) has increased from <5% to ≥ 84%. Coverage with the third dose of DTP vaccine (DTP3) by age 12 months is a key indicator of immunization program performance. Estimated global DTP3 coverage has remained at 83%- 84% since 2009, with estimated 2013 coverage at 84%. Global coverage estimates for the second routine dose of Measles-containing Vaccine (MCV2) are reported for the first time in 2013; global coverage was 35% by the end of the second year of life and 53% when including older age groups. Results showed that more than 111 million infants received vaccines in 2013 to protect them from deadly diseases. These infants account for about 84 percent of the world’s children, but an estimated 21.8 million infants remained unvaccinated, according to new estimates from WHO. Three of WHO’s regions reported very high immunization coverage: the Western Pacific with 96 percent; the European Region with 96 percent; and the Region of the Americas with 90 percent. Coverage was slightly lower in the: Eastern Mediterranean Region at 82 percent; in the South-East Asia Region at 77 percent; and in the African Region at 75 percent. Improvements in equity of access and use of immunization services will help ensure that all children are protected from vaccine-preventable diseases.

Contraceptive Dynamics in Rural Northern Malawi: A Prospective Longitudinal Study.

Increased use of contraceptives in Malawi has not translated into a commensurate reduction in fertility, but the reason is unknown. Insight into contraceptive switching and discontinuation may shed light on this conundrum and on whether the commonly used modern contraceptive prevalence rate (mCPR) is the best indicator of family planning program performance. A one-year prospective longitudinal data set was created from patient-held family planning cards of 4,678 reproductive-age women living in a demographic surveillance site in rural northern Malawi. Contraceptive service data recorded on the women's cards by providers were linked to their socioeconomic, demographic and health data. Contraceptive point prevalence estimates calculated from these data were compared with mCPR estimates from cross-sectional surveys. Survival analyses examined contraceptive adherence. The contraceptive point prevalence of 35% was slightly lower than comparable cross-sectional estimates of mCPR. Only 51% of users of the injectable-the most widely used modern method-received their first reinjection on time, and just 15% adhered to the method for 12 months. Although various study variables were associated with contraceptive use, none were associated with adherence. Gaps in and discontinuation of use of the injectable may play a role in the discrepancy between mCPR and fertility. Interventions to help women adhere to injectable use and to promote long-acting methods should be strengthened.

Immunodeficiency in children starting antiretroviral therapy in low-, middle-, and high-income countries.

The CD4 cell count or percent (CD4%) at the start of combination antiretroviral therapy (cART) is an important prognostic factor in children starting therapy and an important indicator of program performance. We describe trends and determinants of CD4 measures at cART initiation in children from low-, middle-, and high-income countries. We included children aged <16 years from clinics participating in a collaborative study spanning sub-Saharan Africa, Asia, Latin America, and the United States. Missing CD4 values at cART start were estimated through multiple imputation. Severe immunodeficiency was defined according to World Health Organization criteria. Analyses used generalized additive mixed models adjusted for age, country, and calendar year. A total of 34,706 children from 9 low-income, 6 lower middle-income, 4 upper middle-income countries, and 1 high-income country (United States) were included; 20,624 children (59%) had severe immunodeficiency. In low-income countries, the estimated prevalence of children starting cART with severe immunodeficiency declined from 76% in 2004 to 63% in 2010. Corresponding figures for lower middle-income countries were from 77% to 66% and for upper middle-income countries from 75% to 58%. In the United States, the percentage decreased from 42% to 19% during the period 1996 to 2006. In low- and middle-income countries, infants and children aged 12-15 years had the highest prevalence of severe immunodeficiency at cART initiation. Despite progress in most low- and middle-income countries, many children continue to start cART with severe immunodeficiency. Early diagnosis and treatment of HIV-infected children to prevent morbidity and mortality associated with immunodeficiency must remain a global public health priority.

Review of maternal mortality in Ethiopia: a story of the past 30 years.

Ethiopia is one of the six countries which have contributed to more than 50% of all maternal deaths across the world. This country has adopted the millennium development goals (MDGs) including reducing the maternal mortality by three-quarter, and put improvement in maternal health as one of the health sector development program (HSDP) performance indicators. The purpose of this study was to review the maternal mortality ratio (MMR) in Ethiopia in the past 30 years using available literature. A computer based literature search in the databases of MEDLINE, PubMed, HINARI, EBASE, MEASURE DHS, The Cochrane Library, Google Search and Google Scholar was carried out. Manual search for local articles that are not available electronically in full document were also conducted. Eighteen data sources (3 nationally representative surveys, 2 secondary data analyses, 5 small scale community based studies, and 8 hospital based studies) were included in the review. The results of this review are presented in the form of line and stock graphs. The national maternal mortality trend estimated by the central statistics agency of Ethiopia, The Institute for Health Metrics and Evaluation, WHO and other UN agencies showed inconsistent results. Similarly, although there were marked variations in the 95% confidence intervals among individual studies, the small scale community based and hospital based studies have shown that there has been no significant change in maternal mortality over the last three decades. A 22-year cohort analysis from Atat Hospital is the only evidence that demonstrated a very significant drop in maternal mortality among mothers who were kept in the maternity waiting area before the onset of labor. Although the MDG and HSDP envisaged significant improvement in maternal health by this time, this review has shown that the performances are still far from the target. The multisectoral huge investment by the Ethiopian Government is a big hope to reduce the maternal mortality by three-quarters in the near future beyond 2015.

Demonstration program of population-based lung cancer screening in China: Rationale and study design.

BackgroundLung cancer is the leading cause of cancer-related death and has become an enormous economic burden in China. Low-dose spiral computed tomography (LDCT) screening could reduce lung cancer mortality. The feasibility of conducting a population-based lung cancer screening with LDCT in China is uncertain.MethodsIn 2010, a demonstration program of lung cancer screening was initiated in China. High-risk individuals were enrolled in a cluster sampling design in different centers. Participants received baseline and annual screening with spiral CT and follow-up information was collected. The objective of this program is to evaluate the feasibility of conducting population-based LDCT lung cancer screening in the Chinese context. The rates of detection, early diagnosis and treatment are defined as indicators of program performance. The optimal management strategies for nodules are explored in the Chinese context based on experiences in other studies overseas.ResultsA demonstration program of ongoing prospective, multi-center, population-based lung cancer screening is being performed in China.ConclusionsThis demonstration program will provide opportunities to explore the feasibility of LDCT lung cancer screening in the Chinese setting.

Ontario's ColonCancerCheck: Results from Canada's First Province-Wide Colorectal Cancer Screening Program

ColonCancerCheck (CCC), Canada's first province-wide colorectal cancer screening program, was publicly launched in Ontario in April 2008. The objective of this article is to report on key indicators of CCC Program performance since its inception. The CCC Program recommends biennial guaiac-based fecal occult blood test (gFOBT) for persons 50 to 74 years of age at average risk for colorectal cancer and colonoscopy for those at increased risk (having one or more first-degree relatives with a diagnosis of colorectal cancer). Opportunistic screening with colonoscopy is available in Ontario. Five data sources were used to compute indicators of program performance during 2008 to 2011. The indicators computed were FOBT participation, overdue for screening, FOBT positivity, positive predictive value (PPV) of FOBT for colorectal cancer, diagnostic follow-up, and colorectal cancer detection rate. In 2011, FOBT participation was 29.8% and 46.8% of the target population was overdue for screening. FOBT positivity was higher among men (5.1%) than women (3.5%), and the PPV of FOBT for cancer was 4.3% in 2011. Follow-up colonoscopy within 6 months of a positive FOBT was completed by 74.6% of Program participants in 2011. The cancer detection rates for FOBT and for colonoscopy in those with a family history were 1.3 per 1,000 and 4.0 per 1,000, respectively, in 2011. These results provide an early indication of Program performance and provide findings relevant to other organized colorectal cancer screening programs. The greater cancer detection rate in those at increased risk due to family history who undergo colonoscopy screening suggests that a strategy of risk stratification will enhance the impact of FOBT-based screening programs.

공공 건설 프로그램의 기획단계 VE를 위한 다차원 품질모델

건설 프로그램 수준의 복합용도개발사업은 다양한 참여주체들에 의해 장기간에 걸쳐 대규모로 추진되는 사업특성으로 인하여, 사업기간동안 여러가지 갈등이 발생하게 된다. 특히 다양한 프로젝트가 복합된 프로그램 사업의 특성상 참여주체별 요구사항이 상이하여 시설종류 및 규모를 적정하게 계획하는 것이 매우 중요하며, 이를 위해서는 사업의 기획단계에서부터 VE를 실시하여 고객의 요구에 적합한 해결책을 도출할 필요성이 있다. 따라서 본 연구에서는 건설 프로그램 사업의 기획단계 VE 수행에 있어서 발주자의 요구사항을 명확하게 파악하여, 해당 프로그램에 요구되는 적정시설을 제시하기 위한 다차원 품질모델을 개발하였다. 다차원 품질모델 개발을 통해 복합용도개발사업의 12개 성능지표별 15개 주요시설의 특성분포를 제시하였으며, 참여자 요구사항에 따른 적정시설 도출 및 검토, 성능지표간 다차원 합성방안을 제시하였다. 본 연구는 건설프로그램 사업에 기획단계 VE를 적용하기 위한 기본연구로서 의의가 있으며, 본 연구에서 제시한 다차원 품질모델을 통하여 사업초기단계에서 다양한 참여주체들의 요구사항을 기반으로 적정시설을 제시 또는 검토하는 것이 가능할 것으로 기대한다. In the mixed-use development program, several conflicts occur due to the characteristics of construction program, such as large-scale, variety of stakeholders, long periods of time, etc. In particular, since the characteristics of the construction program having various complex projects lead to different requirements depending on stakeholders, it is crucial to plan the appropriate type and size of facilities. Therefore, it is necessary to derive solutions suitable for the needs of owner by conducting VE in the planning phase. In this study, a multi-dimensional quality model is developed to present proper facilities necessary for the construction program by clearly identifying the owner's requirements in performing VE in the planning phase. Through the development of the multi-dimensional quality model, the characteristics distribution of 15 major facilities by 12 performance indicators for mixed-use development programs is presented. The deduction method of appropriate facilities based on the requirements of owner and the multi-dimensional synthesis method among the performance indicators are also suggested. This study is significant as a basic research for the application of VE in the planning phase of construction program. It is expected that the multi-dimensional quality model proposed in this study could facilitate presentation and review of appropriate facilities based on the analysis of requirements of various stakeholders in the early stage of the construction program.

Progress in the establishment and strengthening of national immunization technical advisory groups: Analysis from the 2013 WHO/UNICEF joint reporting form, data for 2012

The majority of industrialized and some developing countries have established National Immunization Technical Advisory Groups (NITAGs). To enable systematic global monitoring of the existence and functionality of NITAGs, in 2011, WHO and UNICEF included related questions in the WHO/UNICEF Joint Reporting Form (JRF) that provides an official means to globally collect indicators of immunization program performance. These questions relate to six basic process indicators.According to the analysis of the 2013 JRF, data for 2012, notable progress was achieved between 2010 and 2012 and by the end of 2012, 99 countries (52%) reported the existence of a NITAG with a formal legislative or administrative basis (with a high of 86% in the Eastern Mediterranean Region – EMR), among the countries that reported data in the NITAG section of the JRF.There were 63 (33%) countries with a NITAG that met six process indicators (47% increase over the 43 reported in 2010) including a total of 38 developing countries. 11% of low income countries reported a NITAG that meets all six process criteria, versus 29% of middle income countries and 57% of the high income ones. Countries with smaller populations reported the existence of a NITAG that meets all six process criteria less frequently than more populated countries (23% for less populated countries versus 43% for more populated ones).However, progress needs to be accelerated to reach the Global Vaccine Action Plan (GVAP) target of ensuring all countries have support from a NITAG. The GVAP represents a major opportunity to boost the institutionalization of NITAGs. A special approach needs to be explored to allow small countries to benefit from sub-regional or other countries advisory groups.

Management of children exposed toMycobacterium tuberculosis: a public health evaluation in West Java, Indonesia

To investigate qualitatively and quantitatively the performance of a programme for managing the child contacts of adult tuberculosis patients in Indonesia. A public health evaluation framework was used to assess gaps in a child contact management programme at a lung clinic. Targets for programme performance indicators were derived from established programme indicator targets, the scientific literature and expert opinion. Compliance with tuberculosis screening, the initiation of isoniazid preventive therapy in children younger than 5 years, the accuracy of tuberculosis diagnosis and adherence to preventive therapy were assessed in 755 child contacts in two cohorts. In addition, 22 primary caregivers and 34 clinic staff were interviewed to evaluate knowledge and acceptance of child contact management. The cost to caregivers was recorded. Gaps between observed and target indicator values were quantified. THE GAPS BETWEEN OBSERVED AND TARGET PERFORMANCE INDICATORS WERE: 82% for screening compliance; 64 to 100% for diagnostic accuracy, 50% for the initiation of preventive therapy, 54% for adherence to therapy and 50% for costs. Many staff did not have adequate knowledge of, or an appropriate attitude towards, child contact management, especially regarding isoniazid preventive therapy. Caregivers had good knowledge of screening but not of preventive therapy and had difficulty travelling to the clinic and paying costs. The study identified widespread gaps in the performance of a child contact management system in Indonesia, all of which appear amenable to intervention. The public health evaluation framework used could be applied in other settings where child contact management is failing.

Effective Coverage for Antiretroviral Therapy in a Ugandan District with a Decentralized Model of Care

IntroductionWhile increasing access to antiretroviral therapy (ART) is reported from many African countries, data on effective coverage particular from settings without external support or research remains scarce. We examined and report effective coverage data from a public ART program in rural Uganda.MethodsWe conducted a retrospective cohort study at all ART-providing governmental health facilities in Iganga District, Eastern Uganda. Based on all HIV patients registered between April 2004 and September 2009 (n = 4775), we assessed indicators of program performance and determined rates of retention and Cox proportional hazards for attrition. Effective ART coverage was calculated using projections (SPECTRUM software) adapted to the district demographic structure and number of people receiving ART.ResultsBy September 2009, district public sector effective ART coverage was 10.3% for adults and 1.9% for children. After a median follow-up of 26.9 months, overall ART retention was 54.7%. The probability of retention was 0.72 (95% confidence interval (CI) 0.69–0.75) at 12 and 0.58 (CI 0.54–0.62) at 36 months after ART initiation. Individual health facilities differed considerably regarding performance indicators and retention. Overall, 198 (16.9%) individual files of 1171 registered ART patients were lost. Young adult age (15–24 years) had a higher risk of attrition (HR 2.1, CI 1.4–3.2) as well as WHO stage I (HR 4.8, CI 1.9–11.8) and WHO stage IV (HR 2.5, CI 1.3–4.7). An interval ≥6 weeks between HIV testing and ART initiation was associated with a reduced risk (HR 0.6, CI 0.47–0.78).ConclusionCompared to reported national data effective ART coverage in Iganga District was low. Intensified efforts to improve access, retention in care, and quality of documentation are urgently needed. Children and young adults require special attention in the program.

The Development of the Emergency Medicine Milestones

The Accreditation Council for Graduate Medical Education (ACGME) has outlined its "Next Accreditation System" (NAS) that will focus on resident and residency outcome measurements. Emergency medicine (EM) is one of seven specialties that will implement the NAS beginning July 2013. All other specialties will follow in July 2014. A key component of the NAS is the development of assessable milestones, which are explicit accomplishments or behaviors that occur during the process of residency education. Milestones describe competencies more specifically and identify specialty-specific knowledge, skills, attitudes, and behaviors (KSABs) that can be used as outcome measures within the general competencies. The ACGME and the American Board of Emergency Medicine (ABEM) convened an EM milestone working group to develop the EM milestones. This article describes the development, use within the NAS, and challenges of the EM milestones.

GAP framework for fresh produce supply

Purpose – Ensuring continued compliance with food safety legislation and market requirements is critical to the fresh produce industry. The purpose of this paper is to analyse how a pre‐requisite programme (PRP) and key performance indicators (KPI) for food safety can be developed for the production of fresh produce, in both low input and high input supply chains.

Tuberculosis in Brazil: last ten years analysis – 2001–2010

ObjectiveTo describe tuberculosis epidemiological situation in Brazil, as well as program performance indicators in 2001–2010 period, and discuss the relationship between changes observed and control measures implemented in this century first decade. MethodsIt is a descriptive study, data source was the Information System for Notifiable Diseases (Sinan), Mortality Information System (SIM), Unified Health System Hospital Information System (SIH/SUS) and TB Multidrug-resistant Surveillance System (MDR-TB/SS). Indicators analyzed were organized into four major groups: TB control program (TCP) coverage and case detection; morbidity; treatment and TCP performance; and mortality. ResultsIn the years analyzed there was a decrease in the number of new cases and incidence rate, mortality reduction (relative and absolute), and improvement in TB detection and diagnosis, as well in TB/HIV coinfection and drug resistance. However, little progress was found in contact investigation, diagnosis in primary care and TB cure rate. DiscussionResults showed many advances in tuberculosis control in the 10 years analyzed, but it also points to serious obstacles that need to be solved so Brazil can eliminate tuberculosis as a public health problem.

Measuring Progress of Waste Management Programs

Proponents of initiatives for solid waste management require tools to assess the efficiency of their programs both environmentally and from the economic and social perspectives, and thus take the appropriate decisions to improve the performance. The objective of this study was to develop an assessment tool through a set of indicators integrated into a model that measures the effectiveness in which programs operate with solid waste management. The methodology consisted in adjusting performance indicators for waste management programs into a Driving Force-Pressure-State-Impact-Response (DPSIR) model. The most relevant indicators were chosen through a selection process that included opinions from experts, literature review based on relevance and applicability to different waste program settings. Eighteen indicators were selected and fitted into the DPSIR model. The model has indicators for causes, pressure, state, impact and response, where the status of each criterion is evaluated. This model will help decision makers optimize the

Executive summary – Performance monitoring for cervical cancer screening programs in Canada

The purpose of this report is to define a core set of performance indicators for organized cervical cancer screening programs in Canada. The goals for establishing a pan-Canadian set of performance indicators are to promote high quality screening through monitoring and evaluation. Over time, with regular monitoring and reporting of these indicators, an evidence base will grow which will permit the setting of pan-Canadian targets.

Promising practices for delivery of court-supervised substance abuse treatment: Perspectives from six high-performing California counties operating Proposition 36

Operative for nearly a decade, California's voter-initiated Proposition 36 program offers many offenders community-based substance abuse treatment in lieu of likely incarceration. Research has documented program successes and plans for replication have proliferated, yet very little is known about how the Proposition 36 program works or practices for achieving optimal program outcomes. In this article, we identify policies and practices that key stakeholders perceive to be most responsible for the successful delivery of court-supervised substance abuse treatment to offenders under Proposition 36. Data was collected via focus groups conducted with 59 county stakeholders in six high-performing counties during 2009. Discussion was informed by seven empirical indicators of program performance and outcomes and was focused on identifying and describing elements contributing to success. Program success was primarily attributed to four strategies, those that: (1) fostered program engagement, monitored participant progress, and sustained cooperation among participants; (2) cultivated buy-in among key stakeholders; (3) capitalized on the role of the court and the judge; and (4) created a setting which promoted a high-quality treatment system, utilization of existing resources, and broad financial and political support for the program. Goals and practices for implementing each strategy are discussed. Findings provide a “promising practices” resource for Proposition 36 program evaluation and improvement and inform the design and study of other similar types of collaborative justice treatment efforts.

Can treatment delay be utilized as a key variable for monitoring the pool of infectious tuberculosis in a population?

A major goal of tuberculosis control programs is to stop community transmission of Mycobacterium tuberculosis. However, this can not be rapidly accomplished because, in endemic areas, most of the population is already infected, serving as a reservoir that continuously contributes to the pool of infectious cases. Tuberculin surveys are the main tools used to monitor the infectious pool, but there are serious methodological constraints, and they require resources and expertise that are often unavailable. There is an urgent need for alternative means to monitor the epidemic at the local level. We investigated whether a systematic registration of treatment delay in the tuberculosis program records of the Amhara Region of Ethiopia could be utilized to estimate the infectious pool of tuberculosis. The study showed that the total number of infectious days and hence an estimate of the infectious pool could be calculated by recording the treatment delay for new TB cases, retreatment cases and failures, and by estimating the number of undiagnosed cases. Of these categories, treatment delay among new smear-positive tuberculosis cases contributes the greatest number of infectious days. A local tuberculosis program can use a systematic recording of treatment delay as a quantifiable variable to monitor the infectious pool, and can also serve as a key indicator of program performance.

Integration of Leprosy Elimination into Primary Health Care in Orissa, India

BackgroundLeprosy was eliminated as a public health problem (<1 case per 10,000) in India by December 2005. With this target in sight the need for a separate vertical programme was diminished. The second phase of the National Leprosy Eradication Programme was therefore initiated: decentralisation of the vertical programme, integration of leprosy services into the primary health care (PHC) system and development of a surveillance system to monitor programme performance.Methodology/Principal FindingsTo study the process of integration a qualitative analysis of issues and perceptions of patients and providers, and a review of leprosy records and registers to evaluate programme performance was carried out in the state of Orissa, India. Program performance indicators such as a low mean defaulter rate of 3.83% and a low-misdiagnosis rate of 4.45% demonstrated no detrimental effect of integration on program success. PHC staff were generally found to be highly knowledgeable of diagnosis and management of leprosy cases due to frequent training and a support network of leprosy experts. However in urban hospitals district-level leprosy experts had assumed leprosy activities. The aim was to aid busy PHC staff but it also compromised their leprosy knowledge and management capacity. Inadequate monitoring of a policy of ‘new case validation,’ in which MDT was not initiated until primary diagnosis had been verified by a leprosy expert, may have led to approximately 26% of suspect cases awaiting confirmation of diagnosis 1–8 months after their initial PHC visit.Conclusions/SignificanceThis study highlights the need for effective monitoring and evaluation of the integration process. Inadequate monitoring could lead to a reduction in early diagnosis, a delay in initiation of MDT and an increase in disability rates. This in turn could reverse some of the programme's achievements. These findings may help Andhra Pradesh and other states in India to improve their integration process and may also have implications for other disease elimination programmes such as polio and guinea worm (dracunculiasis) as they move closer to their elimination goals.