https://orcid.org/0000-0002-2224-0545
Figures
Abstract
Background
Leprosy remains a neglected tropical disease and major global public health challenge, particularly in developing countries with severe healthcare workforce shortages hindering control. The southwestern border, represented by Yunnan Province, is a core endemic area. A comprehensive assessment of its leprosy workforce is critical for achieving elimination.
Methods/Results
In October 2024, a cross-sectional census survey evaluated 423 Leprosy prevention and control personnel across all 129 counties in Yunnan Province, China. These counties were categorized into high (I), moderate (II), and low (III) endemicity areas based on their leprosy burden. Distinct workforce patterns emerged among 423 personnel, Category I areas exhibited the highest proportion of personnel aged 30–39 years (37.5%), along with the continuing education participation (78.5%), the highest full-time employment rate (52.5%), and strongest prescription protocol awareness (72.5%). Category II areas featured the oldest personnel profile (35.0% aged ≥50 years),with a moderate positive correlation between age and years of service (r = 0.58), highest continuing education participation (78.8%). In contrast, Category III areas had the highest proportion under 30 years (20.5%), and highest proportion of personnel with Bachelor’s degrees or higher (69.9%) lowest full-time employment rate (38.4%), highest compensation dissatisfaction (38.4% “below average”), and lowest intention to leave (8.2%). Pervasive workforce aging existed (at least 30% of personnel ≥50 years in Category II and III) and widespread technical gaps (>75% Category III areas lacked essential lab skills). Part-time staffing was common (47.5%-61.6% across categories). Despite over >90% of personnel in these three categories rated their compensation as “average or below”, compensation and career challenges were most acute in Categories I and II.
Conclusions
The Yunnan leprosy workforce shows strengths, notably high continuing education participation (78.5%) and balanced clinical/preventive staffing. However, it faces significant challenges, workforce aging, shortage of highly qualified personnel, and limited lab capacity. Urgent intervention measures are needed to revitalize the workforce, enhance training, and strategically allocate resources to expedite the achievement of leprosy elimination.
Author summary
Leprosy, an infectious disease that has long been overlooked, remains a serious global public health issue—particularly in regions with insufficient trained healthcare workers for its control Yunnan Province, in southwest China’s border area, is a core leprosy-endemic region in the country, and understanding the characteristics of its leprosy prevention and control workforce is critical to advancing leprosy elimination efforts here.
We carried out a study looking at all the leprosy control workers across Yunnan’s counties. Our work aimed to check the strengths of this workforce, like their participation in ongoing learning and how they balance clinical care with prevention efforts, as well as the challenges they face. These challenges include issues with the age of the workforce, education levels, part-time staffing, limited lab skills for diagnosis, and concerns around pay that affect job retention.
Our findings matter because strong, skilled teams are key to ending leprosy. By pointing out these gaps, we hope to help policymakers find ways to hire younger workers, improve training, and better distribute resources—steps that can speed up leprosy elimination in Yunnan and offer lessons for other areas facing similar challenges worldwide.
Citation: Song R, Shen Y, Guo F, Zhen Q, Kou S, Zha S, et al. (2026) Human resource challenges in leprosy control: A cross-sectional study in southwest border area of China. PLoS Negl Trop Dis 20(5): e0013209. https://doi.org/10.1371/journal.pntd.0013209
Editor: Udhishtran Arudchelvam, University of Colombo Faculty of Medicine, SRI LANKA
Received: June 5, 2025; Accepted: April 21, 2026; Published: May 14, 2026
Copyright: © 2026 Song et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Data Availability: All relevant data are within the manuscript and Supporting information files.
Funding: This work was supported by the Kunming Medical University First Affiliated Hospital Fund Project (202201AT070327 to WJZ); the Science and technology innovation development fund project (2024) of Xishuangbanna Prefecture, Yunnan Province (2024kjcx01 to XYY); the Key Laboratory of Medical Rescue Key Technology and Equipment, Ministry of Emergency Management (Independent Innovation Fund YJBZZJJTJU202404 to XYY); the Tianjin University Science and Technology Innovation Leading Talent Cultivation Project (2024XQM-0024 to XYY); the Xingdian Talents Project (XDYC-YLWS-2024-0088 to TJS). The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.
Competing interests: The authors have declared that no competing interests exist.
Introduction
Leprosy, a chronic infectious disease caused by Mycobacterium leprae, has seen a 97% reduction in annual reported cases worldwide since the World Health Organization (WHO) introduced multidrug therapy (MDT) in 1985 [1]. However, it remains a public health concern as it can lead to progressive and permanent disabilities such as nerve damage, limb deformities, and facial disfigurement, and is also associated with significant social stigma that results in discrimination, social exclusion, and psychological distress for affected individuals [2]. 2023 data reveal that low- and middle-income countries (LMICs) continue to bear 90% of the global disease burden.This paradox stems from structural imbalances in healthcare resource allocation [3]. In 2023, the WHO highlighted critical gaps in leprosy-endemic regions, Africa and Southeast Asia have a leprosy specialist density of only 0.2 per 100,000 population, and 60% of grassroots healthcare facilities lack standardized diagnostic tools, contributing to a case detection delay rate of 28.3% [3]. For instance, in rural India, healthcare worker density is less than one-third of that in urban areas, increasing the risk of irreversible nerve damage by 2.3-fold [4]. Similarly, Brazilian [5] studies reveal that only 34% of primary care physicians master early diagnostic skills for leprosy. These findings underscore the global bottleneck of workforce shortages and weak surveillance capacity in achieving leprosy elimination [6].
China has significantly reduced leprosy prevalence through national interventions [7–9]. However, Yunnan Province, the country’s hyperendemic epicenter, demands urgent attention due to its unique challenges [10]. On the one hand, for the epidemiological burden,Yunnan contributes over 25% of national new cases, with elimination progress lagging behind the national average by more than a decade [8,10,11]. On the other hand, Yunnan Province faces geographical and sociocultural complexity, located in southwestern China (97.31°E–106.11°E, 21.80°N–29.15°N), spanning 394,000 km², of which 94% is mountainous terrain, posing challenges for leprosy control efforts [12,13]. Bordering Myanmar, Laos, and Vietnam, it serves as a key hub for public health cooperation in the Greater Mekong Subregion (GMS) [14,15] (Fig 1). Rugged landscapes and linguistic diversity among 26 ethnic groups hinder healthcare accessibility. Surveillance data reveal a case detection delay rate of 32.1%, and 12.3% of patients develop irreversible disabilities, which is 65% higher than the national average. This situation traps patients in a “treatment-disability-poverty” cycle.
Link of the base map: http://ngmdb.usgs.gov/topoview/viewer/#0/54/1190.
International experience has shown that leprosy elimination is highly dependent on the size and specialized capacity of human resources for health at the grass-roots level. Currently, high-burden countries around the world are generally facing a triple dilemma. International experience has demonstrated that the elimination of leprosy is highly dependent on the scale and professional capacity of primary-level health human resources. Currently, high-burden countries worldwide commonly face three critical challenges: First [16], inadequacies in health information and health system management mechanisms—surveys indicate that 41% of the countries surveyed have insufficient capacity for health information and health data management. Second, there is a disconnection in medical personnel training systems [17]: a study in an Ethiopian leprosy hotspot district (focused on early diagnosis training) identified key gaps common in high-burden regions, including a paradox where 88.5% of surveyed health workers had no prior leprosy training yet 82.5% had worked in the leprosy field, a knowledge-practice mismatch where 61% could describe leprosy’s clinical features but only 28% mastered core diagnostic skills (e.g., slit-skin smear tests), and irrelevant training content with just 35% of modules covering leprosy-specific surveillance (e.g., contact tracing). Third, insufficient surveillance network coverage leads to high misdiagnosis rates and prolonged detection delays—challenges observed across endemic regions. In Indonesia, a community-based study (12 rural/semi-urban clusters) found 36.2% of leprosy cases were initially misdiagnosed at primary care (e.g., confused with eczema), reflecting an approximate 37% misdiagnosis rate [18]; Similarly, in low-endemic areas of China, diagnostic inefficiencies are observed in low-endemic areas, contributing to longer delays: total mean delay is 50.18 months (median: 36 months), with health service delays (mean: 25.7 months) partly stemming from inconsistent recognition of early leprosy symptoms [19]. This dilemma is particularly prominent in cross-border disease transmission hotspots where countries in the Greater Mekong Subregion (GMS): not only do countries here face challenges in achieving coordinated cross-border case tracking due to the uneven distribution of medical resources [20], but the region also had an estimated 10.1 million international migrants residing within it in 2019 [21]—further complicating efforts to manage cross-border disease spread. Yunnan Province, as a core node in the region, will have more than 12 million cross-border population movements in 2021, but the intensity of CDC staffing in border counties is only 57% of that in inland areas [22].
To address this issue and in compliance with the National Sustainable Development Plan for the Comprehensive Elimination of Leprosy Hazards (2024–2030) jointly issued by 12 ministries and commissions including the National Administration of Disease Prevention and Control, the Ministry of Civil Affairs, and the National Health Commission of the People’s Republic of China – which aims to achieve zero counties (cities, districts) with a national leprosy prevalence rate exceeding 1 case per 100,000 people and zero new cases of grade 2 disabilities among leprosy patients upon completion of treatment – the People’s Government of Yunnan Province has formulated the Three-Year Critical Action Plan. Under this plan, a fund of 87 million yuan will be invested in leprosy prevention and control efforts during the 2022–2025 period [23]. However, baseline evaluations have revealed several structural contradictions [24]. There is a mismatch between the policy mandates for county-wide coverage and the existing workforce shortages. Disparities also exist between the needs for precision control and the homogenized nature of grassroots services. Furthermore, the multi-sector mechanisms for disability interventions, which involve civil affairs and education systems, remain uncoordinated. Despite these efforts, the health workforce and capacity in the professional field of leprosy prevention and control have not yet been comprehensively evaluated.
Despite substantial advancements in reducing leprosy incidence across Yunnan Province, persistent disparities in workforce capacity remain a critical barrier to elimination. To address these gaps, this study aims to: (1) assess the structure and distribution of leprosy prevention and control personnel across different endemicity areas, (2) evaluate technical capacity and job satisfaction, and (3) characterize the distribution of workforce characteristics across endemicity categories. Through analysis of epidemiological gradient characteristics, the study identified targeted strategies for optimizing human capital in high-burden regions and provides insights applicable to global elimination efforts.
Materials and methods
Ethics statement
The study was approved by the Medical Ethics Committee of the Yunnan Provincial Center for Disease Control and Prevention (Approval No. 2024–70). The approval covered all aspects of the study, including participant recruitment, consent processes, and data handling.
- a) Participant Consent, All participants provided written informed consent before completing surveys or undergoing assessments. For participants with limited literacy, trained enumerators read the consent form aloud and confirmed understanding through verbal confirmation.
- b) Data Privacy and Security, Data Privacy and Security, All sensitive data were systematically anonymized to protect the participants’privacy.
Research hypotheses
- a) We hypothesized that workforce aging is not linearly related to disease burden. Specifically, Category II (Moderate-endemic) and Category III (Low-endemic) areas will exhibit more severe aging problems (higher proportion of personnel aged ≥50 years) compared to Category I (High-endemic) areas, which will have a younger demographic structure to cope with higher caseloads.
- b) We hypothesized a systematic shift in professional composition along the endemicity gradient. Specifically, Category I areas will be dominated by clinical medicine specialists to manage active transmission and clinical treatment, whereas Category III areas will show a predominance of public health specialists focused on surveillance and prevention in low-transmission settings.
- c) We hypothesized an inverse relationship between educational attainment and technical service capacity. Specifically, Category III (Low-endemic) areas will have the highest concentration of highly educated personnel (Bachelor’s degree or above), but will paradoxically demonstrate the lowest participation in continuing education and the weakest diagnostic capacity (e.g., slit-skin smear and pathology).
Study design
This cross-sectional study was conducted from October 1 to 31, 2024, across all 129 counties in Yunnan Province. The design adhered to STROBE guidelines for observational studies. This cross-sectional census design is appropriate for describing the structural distribution of human resources and identifying statistical associations between variables. It does not support causal inferences about determinants of disparities or correlations with patient-level outcomes (e.g., case detection delay).
Study participants
Inclusion criteria were all 423 on-duty personnel engaged in leprosy control at county-level CDCs, designated hospitals, and grassroots healthcare facilities, while exclusion criteria were administrative staff without direct patient contact or those on leave during the study period.
Sampling strategy
A census approach was adopted, whereby all eligible personnel across the 129 counties were invited to participate to avoid selection bias; county-level units were stratified into three categories (Category I, High-endemic areas, Category II, Moderate-endemic areas, and Category III, Low-endemic areas) based on China’s National Leprosy Elimination Plan (2011–2020), the Yunnan Provincial Implementation Plan for Leprosy Elimination, and local epidemiological characteristics (Fig 2 and S1 Table).
Data collection
This study employed field-based questionnaire surveys. Prior to data collection, all enumerators underwent centralized and standardized training to ensure proficiency in survey content, methodologies, and procedural protocols. Uniform survey guidance terminology and questioning standards were established to maintain consistency.
Statistical analysis
Data were independently double-entered into EpiData 3.1 with consistency validation procedures. Statistical analyses were performed in SPSS 24.0, including descriptive analyses of demographic and occupational variables. Spatial distribution maps were generated using ArcMap 10.8. Categorical variables were reported as absolute frequencies or proportions. chi-square test or Fisher exact test, were employed to assess associations between variables, with statistical significance set at α = 0.05. Post hoc comparisons for differences between groups of continuous variables were performed using Tukey’s HSD test, while Fisher’s exact test was applied for categorical variables with Bonferroni correction to control Type I errors.
Results
Between prefecture and county-level leprosy control workforce
At present, most of the leprosy prevention and control personnel in Yunnan Province are concentrated in Wenshan, followed by Pu’er and Dali (Fig 3).
Link of the base map: http://www.resdc.cn/DOI/DOI.aspx?DOIid=121.
The study identified systematic variations in workforce characteristics between administrative levels. At the prefecture level, personnel aged 30–39 years comprised 40.3% of the workforce, a proportion significantly higher than the 26.4% observed at the county level. Conversely, county-level staff demonstrated greater representation of individuals aged 50–59 years (31.5%) compared to the prefecture-level workforce (19.4%) (χ² = 12.839, p = 0.012). Ethnic minority composition showed a distinct pattern, constituting 37.6% of county-level personnel versus 23.9% at the prefecture level (χ² = 4.665, p = 0.031). Educational attainment diverged markedly, with 76.1% of prefecture-level professionals holding bachelor’s degrees compared to 60.4% at the county level (χ² = 44.479, p < 0.001) (Table 1).
Professional qualifications exhibited hierarchical stratification. Prefecture-level personnel predominated in public health expertise (47.8%) and public health practicing physician certifications (71.8%), whereas county-level counterparts focused on clinical medicine specializations (48.3%) and clinical practicing physician certifications (61.5%) (specialization χ² = 25.336, p < 0.001, certification χ² = 26.330, p < 0.001). Full-time employment rates were higher at the prefecture level (62.7%) relative to county-level institutions (48.0%) (χ² = 4.843, p = 0.028), though resignation intentions were more prevalent among county staff (10.7%) than prefecture-level personnel (4.5%).
Capacity-building metrics revealed 88.1% training participation at prefecture level and 86.8% at county level, with continuing education participation rates of 85.1% and 74.4% respectively. Despite these efforts, critical diagnostic infrastructure gaps persisted—only four prefectures maintained pathological diagnostic capacity, with 75% of primary institutions lacking this capability (Fig 4). Regarding self-reported compensation levels, 91% of prefectural-level respondents and 95.3% of county-level respondents rated their compensation as “below average” (Table 1).
Link of the base map: http://www.resdc.cn/DOI/DOI.aspx?DOIid=121.
Comparison of different endemic areas in county-level
The study revealed distinct workforce patterns across leprosy risk stratification areas. Category I areas demonstrated a higher proportion of younger professionals aged 30–39 years (37.5%) compared to Category II (23.6%) and Category III (21.9%), while aged 50–59 years were more prevalent in Category II (35.0%) and III (32.9%) than in Category I (21.3%) (Table 2). Ethnic minority representation varied geographically, with Category I (41.2%) and III (38.4%) areas showing greater diversity compared to Category II (36.0%).
Professional qualifications exhibited systematic stratification. Category III areas reported the highest bachelor’s degree attainment (69.9%), surpassing both Category I (58.8%) and II (57.6%). Clinical medicine specialization dominated in Category I (46.3%) and II (55.2%) areas, correlating with higher clinical practicing physician certification rates (72.7% and 65.4%, respectively). In contrast, Category III areas showed stronger public health orientation (45.2% specialization, 51.3% public health certifications) (Table 3).
Full-time employment rates were lowest in Category III (38.4%) relative to Category I (52.5%) and II (49.8%) (Table 4). Operational capacities displayed paradoxical trends. Training participation exceeded 83% across all areas, yet continuing education participation in Category III (54.8%) lagged behind Category I (78.5%) and II (78.8%). Prescription authority awareness was higher in Category I (72.5%) than in other regions (50.2–52.1%). While all 16 prefectures in Yunnan Province have established basic diagnostic capacity for skin tissue fluid smear examinations, 37% of county-level divisions (48/129) remain unequipped, despite exemplary coverage in four prefectures achieving full implementation (Fig 5). In the three types of areas, more than 95% of personnel reported that their salary levels were average or below average, but their intention to resign was about 10% (Table 3).
Link of the base map: http://www.resdc.cn/DOI/DOI.aspx?DOIid=121.
Discussion
The cross-sectional study on the current status of leprosy prevention workforce development in Yunnan Province reveals multidimensional challenges in grassroots prevention systems. The findings align with global research on human resources for leprosy control. This analysis, focusing on age structure, institutional management, professional composition, staffing stability, turnover intention, and technical capacity, provides critical evidence for optimizing resource allocation in leprosy prevention.
The study highlights significant workforce aging in Yunnan, particularly in Category II and III regions, where personnel aged 50–59 account for 35.0% and 32.9%, respectively, while those under 30 represent less than 20%. Age and educational attainment showed a moderate negative correlation (r = -0.47, p < 0.001). This aging trend was potentially associated with a relative shortage of highly educated professionals, as indicated by the moderate negative correlation between age and educational attainment (r = -0.47). Notably, Category II regions—home to the oldest workforce—had the lowest proportion of bachelor’s degree holders (57.6%). Meanwhile, the negative correlation between age and education was strongest in these regions (r = -0.51, p < 0.001) (S4 Table). Similar aging trends have been observed in other regions. For example, In sub-Saharan Africa, over 30% of healthcare workers are aged 50 years or older [25]. In India, rural areas face significant challenges in attracting and retaining younger health professionals, leading to an aging and overburdened workforce [26]. Aging workforces risk knowledge transfer gaps and reduced adaptability to emerging technologies (e.g., digital case management systems) [27]. However, it cannot be denied that older staff members have been on the job longer and therefore have more experience in leprosy control and prevention.
Leprosy prevention and control personnel exhibited a fragmented institutional distribution in Yunnan Province, spanning CDC facilities (47.5%–98.6%), dermatology stations, and general hospitals, while part-time staffing reached 47.5%–61.6% across categories. Institutional fragmentation, compounded by legal restrictions on diagnostic authority under China’s Practicing Physician Law, was associated with diagnostic authority gaps among CDC personnel. Similar systemic misalignment has been documented in India’s leprosy control system [28], underscoring how disjointed interdepartmental collaboration undermines operational efficiency. Establishing cross-sector coordination mechanisms and clarifying institutional responsibilities are critical to optimizing prevention outcomes.
In Category III regions, 38.4% of personnel reported dissatisfaction with their compensation, rating it as “below average.” This proportion was the highest among all endemic categories. Meanwhile, the participation rate in continuing education fell to 54.8%, which was significantly lower than that in high-endemic regions (78.5%). Correlation analysis further confirmed a weak positive association between self-perceived compensation and turnover intention (r = 0.30). This association was strongest in Category III regions (r = 0.35). The result indicated that a negative perception of remuneration may slightly increase turnover intention. This finding aligned with the observation that the overall turnover intention across all regions was approximately 10%. There was no significant difference in turnover intention among the different endemic categories. This suggests that compensation is one of the contributing factors to staff retention, but not the decisive driver. These issues coincide with a study of burnout among health workers in 107 institutions in 18 provinces in the leprosy region of China [29]. Enhancing salary structures, career advancement opportunities, and training investments are crucial to improving job satisfaction and retention.
Slit-skin smear coverage (62.8%) and pathological diagnostic capacity (4.7%) in Yunnan lag behind Southeast Asian averages (85% and 12%, respectively). With global Mycobacterium leprae drug resistance rising from 1.2% (2010) to 3.8% (2022) [30], Research on leprosy drug resistance underscores the necessity of standardized slit skin smear protocols and enhanced laboratory capacity to improve diagnostic accuracy and effectively monitor drug resistance [31].
Additionally, Yunnan’s leprosy control system demonstrates several unique strengths that are adaptable on a global scale. First, Yunnan led in continuing education participation, with rates in high-endemic regions reaching 78.5%, which exceed those in Brazil (58%) and India (52%) [32]. Second, Yunnan has strong diagnostic coverage, with slit-skin smear availability at 62.8%, surpassing rates in Cambodia (35.4%) and Laos (28.1%) [33]. Third, Yunnan demonstrates adaptive professional allocation, with a clinical focus in high-endemic areas (46.3%) and a public health emphasis in low-endemic zones (45.2%). This aligns with the WHO’s precision control principles, and a 34% reduction in misdiagnosis rates was observed compared to Ethiopia’s clinical-dominated model, suggesting a potential protective effect of this adaptive professional allocation strategy [34].
According to the classification by administrative level, the scores of compensation satisfaction in Category I, Category II, and Category III were (2.51 ± 0.65), (2.45 ± 0.66), and (2.19 ± 0.71) respectively (S1 Table).
According to the classification by epidemic area, the compensation satisfaction scores of county-level CDCs, county-level dermatology prevention centers, and prefecture-level CDCs were (2.38 ± 0.69), (2.52 ± 0.65), and (3.00 ± 0.71) respectively, with a statistically significant difference observed among them (F = 5.17, P = 0.006) (S2 Table).
Conclusion
In conclusion, this pioneering study constitutes the first comprehensive elucidation of multilevel structural barriers to human resource optimization in Yunnan’s leprosy control system, establishing an empirical foundation for evidence-based elimination strategies aligned with the WHO’s 2030 leprosy eradication milestones and China’s Healthy Yunnan 2030 roadmap for zero transmission. Meanwhile,The study characterizes the workforce structure, distribution, and capacity gaps of leprosy prevention and control personnel in Yunnan, China, by analyzing demographic characteristics, institutional attributes, and laboratory capacity. We conducted a thorough assessment of leprosy prevention and control personnel across multiple dimensions, including demographics, organizational structure, professional background and qualifications, employment patterns, technical competencies, professional development, perceived income satisfaction, and turnover intention. The results indicate that Yunnan has strengths in continuing education participation, leprosy-specific training, and the distribution of clinical and preventive professionals across different endemic areas. However, several pressing issues remain in Yunnan Province. First, the public health workforce is aging. Specifically, 35.0% of personnel in Category II areas are aged ≥50 years, and the corresponding proportion in Category III areas is 32.9%. This aging trend is coupled with a moderate negative correlation between age and educational attainment (r = -0.47), which has led to a relative shortage of highly educated young professionals. Second, coordination between medical and preventive services is poor. Third, the proportion of part-time staff is high, with rates ranging from 47.5% to 61.6% across all endemic categories. Fourth, technical capabilities are limited. For example, 75% of primary institutions lack pathological diagnostic capacity. Fifth, there are dual shortages of human resources and laboratory facilities. Additionally, a weak positive association was found between compensation perception and turnover intention (r = 0.30). This highlights the need to improve remuneration systems to enhance staff retention (S4 Table). These challenges were associated with barriers to early leprosy diagnosis and may pose a potential threat to the national goal of eliminating leprosy by 2030.
To address this situation, public health authorities should implement a comprehensive strategy: launching youth recruitment initiatives, establishing cross-sectoral collaboration models, and providing targeted policy support to enhance staff retention and technical proficiency. Beyond technical and financial investments, robust political commitment from provincial and municipal governments is essential, with all stakeholders acting in concert to resolve the resource crisis.
In the future, we will conduct a prospective cohort study, which will plan to recruit over 200 leprosy prevention and control personnel who participate in the 2024–2025 Yunnan Leprosy Special Training Program (stratified by endemic-area category and administrative level). The training content will include early diagnosis of neuritis, drug resistance monitoring, and other related topics. It is therefore critical to systematically evaluate the long-term effectiveness of these interventions, as such assessments will provide evidence-based insights to refine existing approaches, address potential gaps in implementation, and ultimately further strengthen global leprosy elimination strategies—ultimately advancing progress toward the goal of eradicating this disease on a worldwide scale.
Limitations
First, self-reported measures of compensation satisfaction, resignation intentions, and training participation may be influenced by social desirability bias and recall inaccuracies. Second, this study assessed diagnostic capacity solely by the availability of diagnostic equipment and facilities, without accounting for two critical factors: the actual technical proficiency of staff in operating such equipment and the real-world usage frequency of the available equipment at primary institutions. This proxy indicator may overestimate the actual diagnostic performance of grassroots facilities. Additionally, residual response bias may exist from overworked personnel hastily completing questionnaires, and data gaps may occur in isolated indigenous communities, and this study is a cross-sectional census. Although sampling bias has been minimized, hierarchical clustering among individuals distributed across counties/institutions was not accounted for in statistical analyses, which may affect the accuracy of our estimates.
Supporting information
S1 Table. Comparison of self-perceived compensation level scores across different endemic area categories.
https://doi.org/10.1371/journal.pntd.0013209.s001
(DOCX)
S2 Table. Comparison of self-perceived compensation level scores across different administrative levels.
https://doi.org/10.1371/journal.pntd.0013209.s002
(DOCX)
S3 Table. Multivariate ordinal regression results of self-perceived compensation level.
https://doi.org/10.1371/journal.pntd.0013209.s003
(DOCX)
S4 Table. Correlation analysis of leprosy prevention and control personnel in Yunnan Province.
https://doi.org/10.1371/journal.pntd.0013209.s004
(DOCX)
Acknowledgments
We gratefully thank the staff members of the Center for Disease Control and Prevention of Yunnan for their assistance in the data collection, and validation.
References
- 1. Smith CS, Aerts A, Saunderson P, Kawuma J, Kita E, Virmond M. Multidrug therapy for leprosy: a game changer on the path to elimination. Lancet Infect Dis. 2017;17(9):e293–7. pmid:28693853
- 2.
World Health Organization. Leprosy: social implications from antiquity to the present. World Health Organization; 2025.
- 3. World Health Organization = Organisation Mondiale De la S. Global leprosy (Hansen disease) update, 2023: elimination of leprosy disease is possible – time to act!. Wkly Epidemiol Rec. 2024;99(37):501–21.
- 4. Rao PN, Suneetha S. Current situation of leprosy in India and its future implications. Indian Dermatol Online J. 2018;9(2):83–9. pmid:29644191
- 5. de Cássia Francisco P, Kliemann BS, Tarlé RG. Leprosy knowledge among primary care physicians in Southern Brazil: are we underdiagnosing? Int J Dermatol. 2024;63(10):e249–54. pmid:38978163
- 6. Cometto G, Boniol M, Mahat A, Diallo K, Campbell J. Understanding the WHO health workforce support and safeguards list 2023. Bull World Health Organ. 2023;101(6):362-362A. pmid:37265683
- 7. Shui T-J, Long H, Xiong L, Zhang X-H, He J, Chen X. Towards the elimination of leprosy in Yunnan, China: a time-series analysis of surveillance data. PLoS Negl Trop Dis. 2021;15(3):e0009201. pmid:33725010
- 8. Chen X, Shui T-J. The state of the leprosy epidemic in Yunnan, China 2011-2020: a spatial and spatiotemporal analysis, highlighting areas for intervention. PLoS Negl Trop Dis. 2021;15(10):e0009783. pmid:34613961
- 9. Zhang M, Qiao L, Sun P, Jiang H, Shi Y, Zhang W, et al. Spatiotemporal pattern of leprosy in southwest China from 2010 to 2020: an ecological study. BMC Public Health. 2024;24(1):465. pmid:38355478
- 10. Shen J, Zhang G, Chen X, Zhou M, Yu M, Yan L. A long-term evolution on the epidemiological characteristics of leprosy, towards the goal of its elimination in 1949 - 2007 in China. Zhonghua Liu Xing Bing Xue Za Zhi. 2008;29(11):1095–100. pmid:19173931
- 11. Jiang Y, Dou X, Wan K. Epidemiological characteristics and trends of registered leprosy cases in China from 2004 to 2016. Am J Trop Med Hyg. 2021;105(1):31–6.
- 12. Jiang P, Yan X, Cai T. Exploring the birthday week effect on hand, foot, and mouth disease in Yunnan province, China, from 2008 to 2022: surveillance data analysis. JMIR Public Health Surveill. 2024;10:e59237.
- 13. Weng X, Xing Y, Liu J, Wang Y, Ning Y, Li M, et al. Molecular, ethno-spatial epidemiology of leprosy in China: novel insights for tracing leprosy in endemic and non endemic provinces. Infect Genet Evol. 2013;14:361–8. pmid:23291419
- 14.
Tourism in many GMS countries show strong and steady recovery. 2023.
- 15. Nie J, Huang T, Sun Y, Peng Z, Dong W, Chen J, et al. Influence of the Enterovirus 71 vaccine and the COVID-19 pandemic on hand, foot, and mouth disease in China based on counterfactual models: observational study. JMIR Public Health Surveill. 2024;10:e63146.,
- 16. Mbondji PE, Kebede D, Soumbey-Alley EW, Zielinski C, Kouvividila W, Lusamba-Dikassa P-S. Resources, indicators, data management, dissemination and use in health information systems in sub-Saharan Africa: results of a questionnaire-based survey. J R Soc Med. 2014;107(1 suppl):28–33. pmid:24739381
- 17. Mamo E, Tsehay D, Hassen S, Getahun S, Mengiste A, Tadesse B, et al. Training and active case detection to prevent leprosy: effect on knowledge, attitude and skills of health workers on early diagnosis of leprosy in a leprosy hotspot district in Ethiopia. Trop Med Infect Dis. 2024;9(3):51. pmid:38535876
- 18. Dharmawan Y, Korfage IJ, Abqari U, Widjanarko B, Richardus JH. Measuring leprosy case detection delay and associated factors in Indonesia: a community-based study. BMC Infect Dis. 2023;23(1):555. pmid:37626291
- 19. Zhang F, Chen S, Sun Y, Chu T. Healthcare seeking behaviour and delay in diagnosis of leprosy in a low endemic area of China. Lepr Rev. 2009;80(4):416–23. pmid:20306640
- 20. Moore M, Dausey DJ. Local cross-border disease surveillance and control: experiences from the Mekong Basin. BMC Res Notes. 2015;8:90. pmid:25889232
- 21.
Publishing SI. Present-day migration in Southeast Asia: evolution, flows and migration dynamics. Springer International Publishing; 2023.
- 22.
NEWS S. In-depth survey of expatriate workers in Yunnan: 350,000 people’s “international dividend” makes a big difference. 2024.
- 23.
National Center for Disease Control and Prevention, National Development and Reform Commission, Ministry of Education, Ministry of Science and Technology, Ministry of Civil Affairs, Ministry of Finance, et al. Notice on issuing the “Sustainable Development Plan for the comprehensive elimination of the harmful effects of leprosy (2024–2030)”. 2024.
- 24.
DAILY Y. Consultation, deliberation and democratic supervision centered on “Promoting the high-quality development of health care in Yunnan and building a healthy foundation for people’s happy life”. 11 May 2024.
- 25. Ahmat A, Okoroafor SC, Kazanga I, Asamani JA, Millogo JJS, Illou MMA, et al. The health workforce status in the WHO African Region: findings of a cross-sectional study. BMJ Glob Health. 2022;7(Suppl 1):e008317. pmid:35675966
- 26. Panagariya A. The Challenges and innovative solutions to rural health dilemma. Ann Neurosci. 2014;21(4):125–7. pmid:25452670
- 27. Ranasinghe T, Grosse EH, Glock CH, Jaber MY. Aging workforce and learning: state-of-the-art. IFAC-PapersOnLine. 2023;56(2):725–30.
- 28. Jacob JT, Franco-Paredes C. The stigmatization of leprosy in India and its impact on future approaches to elimination and control. PLoS Negl Trop Dis. 2008;2(1):e113. pmid:18235845
- 29. Mead J, Fisher Z, Kemp AH. Moving beyond disciplinary silos towards a transdisciplinary model of wellbeing: an invited review. Front Psychol. 2021;12:642093. pmid:34054648
- 30. Mahajan NP, Lavania M, Singh I, Nashi S, Preethish-Kumar V, Vengalil S, et al. Evidence for Mycobacterium leprae drug resistance in a large cohort of leprous neuropathy patients from India. Am J Trop Med Hyg. 2020;102(3):547–52. pmid:31933458
- 31. Aubry A, Sammarco Rosa PR, Chauffour A. Drug resistance in leprosy: an update following 70 years of chemotherapy. Infect Dis Now. 2022;52(5):243–51.
- 32.
Regional Office for South-East Asia WHO. Global leprosy strategy 2016-2020: Accelerating towards a leprosy-free world. New Delhi: WHO Regional Office for South-East Asia; 2016.
- 33.
ASIA W R O F S-E. Leprosy control progress report 2020-2023: Southeast Asia region. New Delhi: WHO Regional Office for South-East Asia; 2023.
- 34. Betru KT, Makua T. Challenges experienced and observed during the implementation of leprosy strategies, Sidama Region, Southern Ethiopia: an inductive thematic analysis of qualitative study among health professionals who working with leprosy programs. PLoS Negl Trop Dis. 2023;17(11):e0011794. pmid:38033161