Over the last few years, there have been significant changes in philosophy and practice in leprosy rehabilitation programmes. With the integration of leprosy services into general health services these programmes are no longer vertical, stand-alone services, and are moving from a medical model where prevention and reversal of deformities were the prime focus of interventions, to a psychosocial model with emphasis on inclusion, economic rehabilitation, and access to other services and human rights. These shifts and changes have thrown up challenges as well as opportunities.

While it is clear that there will continue to be demands for care by persons affected by leprosy, it is not yet clear who will actually benefit from community level rehabilitation to address the economic and other psychosocial impact of the illness. Studies have shown that a significant proportion of persons affected by the disease tend to grow poorer, especially those with deformities. However, not all persons with deformities deteriorate economically. Conversely, some persons without deformities tend to slide down the economic ladder. There are also issues related to motivation and expectations of benefits from some sections of the affected population who have been used to charity.

Leprosy rehabilitation programmes until recently tended to be more institution based and charity-based. The current transition from medical to psychosocial, and from institutional to community based processes, in line with the move towards promoting rights and inclusion, would need much capacity building at all levels to adopt these approaches.

On the side of opportunities, many leprosy hospitals are in an advantageous position to develop services for other groups of persons with disabilities, utilising their existing expertise. They can develop expanded community based rehabilitation programmes to cover persons with different disabilities, playing a referral, training and support role. At the field level, the workers and volunteers can form the first level contact with the larger community. Some hospitals with a CBR programme can grow into centres for training of CBR personnel, with the institutional back up and other resources available with them. Along with training, the potential to develop research projects in CBR is also good, as is being done in some centres.

This volume has many articles on persons affected by leprosy, highlighting issues of concern. Leprosy rehabilitation programmes that are moving towards decentralised and community based strategies need to keep these issues in mind as they shift their focus from a `client- centred programme' to a `client and community centred programme'.

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