In His Own Words: India Showcases DCPP Successes

In His Own Words: India Showcases DCPP Successes

By Mr. Rajiv Misra

During Mr. Rajiv Misra's long and distinguished career in the Indian civil service, he served as Permanent Secretary in both the Ministry of Finance and the Ministry of Health. He was instrumental in using the main findings of Disease Control Priorities in Developing Countries, published in 1993, to reshape Indian health policy and programs in the 1990s, based on the best available scientific evidence. Mr. Misra has become one of India's foremost experts on global health policy. In 2003, Oxford University Press published the India Health Report produced by a team led by Mr. Misra.

The success of an endeavour should be judged in relation to its underlying objective. The Disease Control Priorities Project (DCPP) produced landmark publications in 1993 and 2006 that sought to gather, collate, and analyze the best available knowledge on public health, and present it in a manner that would enhance awareness and understanding of public health issues in developing countries—among all stakeholders, as well as within the donor community—and eventually improve the quality of decisionmaking.

If that is the underlying mission, it also follows that the impact of the project should be evaluated by examining how, if at all, its publications influenced the decision-makers in the developing countries and their development partners in the identification, design, and implementation of projects. Further, it would be important whether the impact was only ephemeral or whether it helped foster a culture of scientific and evidence-based decisionmaking. This narration seeks to present the experience from India, which by all accounts, was a major beneficiary from the first DCPP project. India’s story would show the great potential of such publications provided there is a receptive environment in the developing countries coupled with financial support from the donor community.

It often requires a major crisis to shake a country out of its inertia and make it open to new ideas and new ways of doing things. At the time of its independence, India had accepted the socialist model of a planned economy consistent with a parliamentary democracy. This led to the development of a mixed economy but with tight and all-pervasive controls by the state. Further, the shadow of colonial domination and exploitation led to a very inward looking economy that emphasized self-reliance and import substitution. This policy, though yielding some initial dividends, became a major impediment to foreign and domestic private investment, technological development, and international trade and contributed to very low rates of economic growth. But little changed until 1990, even when the serious consequences of these policies were evident due to ideological resistance and vested interests. Then, an unprecedented fiscal and balance of payments crisis forced the government to seek structural adjustment lending from the International Monetary Fund (IMF) and the World Bank. The economy was opened up, the regulatory structure was largely dismantled, and governance opened up to new ideas. These changes have arguably been responsible for India achieving robust growth rates and being universally recognised as an emerging economic power.

This was the scenario when I was shifted from the Finance Ministry to the Health Ministry in the beginning of 1991, following a change of government. A review of important disease control programs revealed that almost all were performing poorly on account of inadequate financial resources, outdated technology, and mismanagement. The only exception was the Leprosy Eradication Programme, which by and large, had done well. There were many programs that were totally unproductive. A few, like tuberculosis (TB), were doing more harm than good by relying on an intermittent supply of drugs based on outdated protocols, which were arguably contributing to the development of drug resistance. Making any real improvement in these programs required investments of an order unthinkable in an environment of fiscal compression imposed by IMF. There was little experience of external assistance in the Health Ministry, as with the exception of population control, no major projects had ever been either negotiated or even encouraged by the Finance Ministry.

Luckily, the World Bank was, at that very time, revising the policy regarding its lending arm—the International Development Association (IDA)—and shifting future lending to social sectors. India happened to be the largest beneficiary of IDA. Traditionally it constituted an important source of foreign exchange that was even more important at a time of severe external account imbalances. The Finance Ministry had no option but to encourage the Education and Health Ministries to prepare projects for IDA assistance. There was, however, no incentive for the social sector ministries to make the extra effort to seek World Bank loans as external assistance did not lead to any additional budget allocations. The government required that additional outlay from externally aided projects be adjusted by a corresponding reduction in other programs to keep the overall budgetary ceilings unaltered. It was tantamount to robbing Peter to pay Paul. Unfortunately, this remains the rule even today except when state governments borrow directly. Obviously, the Education Ministry was not interested in the hard work of applying for World Bank loans without any hope of extra funds as a reward. But having come from the Finance Ministry, and fully aware of the perilous balance of payments position, I was confident that the government would be compelled to treat the IDA money as additional funds if we took a firm stand. I was thus prepared to take the risk and attempt to tap this source without compromising the outlays for other programs. My confidence was fully vindicated when, in each case, the Finance Ministry reluctantly agreed to treat the IDA assistance as additional to the budgeted outlays—after our refusal to negotiate the project in the absence of such an assurance.

Fortunately for us in the Health Ministry, the team at the South Asia division of the World Bank was extraordinarily supportive and accommodating. They encouraged and helped us at every stage. Our staff had to be trained in writing project reports and to become familiar with procurement and accounting procedures for World Bank-assisted projects. The World Health Organization (WHO) also chipped in with technical assistance. It became a standard practice to associate WHO technical personnel with each and every World Bank mission, in addition to experts from other organisations like the U.S. Centers for Disease Control and Prevention (CDC) and UNICEF, wherever necessary.

The first project taken up was for HIV/AIDS. It did not require any analytical exercise to identify this as the most urgent priority. Not only was there no worthwhile control program in place, even a proper surveillance mechanism had not been established to face this emerging threat. Although, the first HIV-positive case had been detected in India in1986, it was generally regarded as a foreigners’ disease. Responses were limited to compulsory tests for foreigners visiting for longer durations and to better testing facilities at blood banks. It was generally believed that the national cultural traditions of partner fidelity would be more than sufficient to prevent the spread of the disease. In fact, the proposal for World Bank assistance for HIV/AIDS encountered huge resistance domestically among civil society, political parties, and the media on the grounds that the proposal was in response to World Bank/WHO pressure and would divert attention and resources from other vital programs like TB and malaria.

Fortunately, we were able to convince the political masters that this new threat required a systematic multi-faceted response that was possible only with the assistance of international agencies that had experience dealing with HIV/AIDS. There was huge resistance from the states. Many refused to use the grants to set up the required organisational structures.. It was only persistent effort and persuasion that ultimately started yielding results. A number of successor projects followed, and today we can look back with some satisfaction as the latest estimates show a reduction in prevalence in some of the worst affected southern states. HIV/AIDS continues to be a serious threat even today, but one shudders to think of the scenario had we yielded to popular perception and neglected to take this up as a major priority in 1991.

Luckily, the analytical work of DCP1 came to India even before its formal publication in 1993. A seminar in early 1992, organized by the DCPP team at the prestigious All India Institute of Medical Sciences in Delhi (which I had the privilege to chair), introduced us to the systematic application of tools of economic analysis to public health issues. It was indeed an eye opener. We had never before believed that decisions on allocation of resources and identification of projects could be based on quantifiable data on the burden of disease and the cost-effectiveness of interventions. The presentations on demographic change and the consequent epidemiological transition were again an altogether new way of looking at future challenges and opportunities.

There was some understandable scepticism about the methodologies for computing these numbers, but the presentations of Dean Jamison and his colleagues made a deep impression. Since we were looking for objective criteria to identify projects to be positioned for World Bank assistance, the innovative approaches of DCP1 came in handy at a most opportune time. The DCP1 analyses were incorporated in the World Bank’s World Development Report 1993, which became by far the most influential publication on public health issues in developing countries. The analytical tools developed by DCP1 were thus readily adopted by the lending operations of the World Bank.

Thus, a serendipitous set of circumstances led to an unprecedented partnership between the health ministry and the World Bank for revamping and scaling up major disease control programs identified on the basis of DCPP concepts of disease burden and cost effectiveness. As a result, the developmental outlays for the Department of Health (as distinguished from the Department of Family Welfare responsible for population control and maternal and child health (MCH) programs) rose more than five-fold—and the external component more than 25-fold— between 1990-1991 and 2001-2002, as reported in the 2003 India Health Report. The component of external funding in major disease control programs (malaria, TB, leprosy, AIDS, and blindness) in 2002-2003 was as high as 73 percent, according to the National Commission on Macroeconomics and Health. Besides increasing the financial resources beyond anyone’s expectations at a time of severe financial crisis, this completely changed the way projects were formulated, implemented, monitored, and evaluated. The new approach resulted in a huge gain in the efficient use of resources, as well as, the delivery of interventions.

I left the Health Ministry in 1994 following superannuation from civil service. But by then the identification of projects applying DCP1 criteria and the submission of proposals to the World Bank for all the disease control projects, with the sole exception of malaria, had been completed. And two of the projects—AIDS and leprosy—had been approved. Despite some unfortunate delays, all the projects were followed up and implemented.

After HIV/AIDS, the next project identified was for leprosy, which was already an acknowledged success thanks to the proven technology, dedicated personnel, and the active participation of civil society. The program had already succeeded in drastically reducing new infections in the worst-affected states in southern India. The challenge was to expand the successful model to cover endemic areas in the northern and the eastern states. Our analyses also found treating leprosy to be one of the most cost-effective interventions. It is a matter of great satisfaction that the target of eliminating leprosy (with a prevalence of less than 1 case per 10,000 population) for the country as a whole was finally achieved in 2005.

If evidence-based decisionmaking was indeed the underlying objective of DCPP, there could not be a better example than the Cataract Blindness project. A national survey of blindness done in 1985 by the All India Institute of Medical Sciences in Delhi and published in 1990 made the startling revelation that over 80 percent of the nation’s blindness was caused by senile cataract. In other words, the infrastructure for eye care had not expanded sufficiently to cope with the needs of the aging population—a direct consequence of the demographic and epidemiological transition that we had discussed at the DCPP seminar referred to above. Although people were living longer, many were spending their later years in darkness because the health system had failed to address this growing need. There could not be a more worthy object for state intervention, and the condition was curable at a very small cost.

Another first in this project was the selection of 10 states strictly based on cataract blindness prevalence data provided by the 1985 survey. The only exception was for the state of Jammu and Kashmir, which, though high on blindness prevalence, was excluded due to the prevailing security situation. The use of evidence-based data to select program sites was quite revolutionary; such selections were routinely made only on political considerations. The project, approved by the World Bank in 1995, was a great success. It not only helped to wipe out the estimated backlog of 7 million cataract surgeries, but it also permanently strengthened the opthalmic infrastructure to cope with the future requirements of an aging population. During the 1995-2002 period, 15.35 million surgeries were conducted under the project— against the target of 11.03 million. Most of the surgeries used the latest intraocular lens (IOL) implant technology, which was hitherto the privilege of only the affluent few. It also fostered public-private partnership on an unprecedented scale. It is gratifying that the project has been chosen for inclusion in the revised version of the publication ‘What Works,’ a global listing of outstanding examples of successes in health interventions by the Centre for Global Development, Washington D.C.

Both TB and malaria were obvious priorities when considering disease burden as well as cost effectiveness. However, projects to combat both diseases were delayed until 1997. The TB program had been evaluated under WHO auspices by an international team, which had given an alarming report about the almost total ineffectiveness of the program. TB control had also acquired a new urgency due to the threat of a double epidemic consequent on rapidly spreading HIV infections. The obvious course was to apply the internationally proven DOTS strategy to control TB, which admirably fulfilled the cost-effectiveness criteria rapidly all over the country. However, the disbursement of funds was suspended in 1998 for two years because of differences between the World Bank and the Indian government on procurement issues. The project, therefore, could start in earnest only in 2000. But after these initial hiccups, the project has not looked back, and now DOTS is found throughout the country, helped by additional assistance from the U.K. Department for International Development. The project has achieved a cure rate of 86 percent, which is comparable to the best results anywhere in the world.

The malaria project was also approved only in 1997 because of a lack of consensus on strategy. Past efforts at vector control were not delivering the desired results. In any case, in the worst-affected forest areas inhabited largely by tribal populations, vector control was not a feasible option given the environmental conditions. The focus had to shift to prevention, early detection, and treatment, which required strengthening the health services and strong community participation in remote areas. The project preparation understandably took more time. Considering the challenges and the difficult operating conditions, it is too early to judge the outcomes.

As the disease-specific projects progressed, it was becoming increasingly clear that this approach had its limitations, and that the strengthening of state health systems was essential for lasting improvement and sustainability. Health systems projects were negotiated directly by the World Bank with the states, starting with Andhra Pradesh in 1995. Subsequently, similar projects were undertaken in several other states including Karnataka, Punjab, Uttar Pradesh, and West Bengal. These projects seek to upgrade capacity at the state and district level and to strengthen and modernise the secondary level of public health care. The results are mixed and depend very much on the quality of governance in the concerned state.

Despite some delays and hold-ups, these projects have been hugely successful. India’s progress on health indicators in the last decade has not been as spectacular as one would have wished. However, in areas where specific projects were undertaken with external assistance, the results have generally been very gratifying. It is not difficult to imagine what could have been the situation today had these initiatives not been taken in the 1990s. The collaborative effort of the Indian government and the World Bank was greatly facilitated by the application of DCP1 concepts for channelling additional resources to cost-effective interventions dealing with the conditions responsible for a major share of the disease burden. A question that is legitimately raised is whether—instead of the disease-specific strategy—it would have been better to focus on system strengthening. It must be appreciated that the latter is entirely in the domain of the states where there was little awareness or understanding for the need of system reform, which, in any case, is a difficult and slow process and succeeds only in an environment of good governance. It is conceded that more could perhaps have been done to prepare the states for system reform, but given the prevailing environment, disease-specific projects were the only option for controlling major causes of the disease burden in a reasonable timeframe.

This narrative brings out the significant and positive contribution that DCP1 made to the choice of interventions and allocation of resources in the health sector for the Indian government, as well as for donor agencies. The question that naturally arises is whether and to what extent this is replicable in India and other developing countries with reference to DCP2. As explained earlier, the positive influence of DCP1 in India was due to many highly favourable factors and thus it is difficult to predict what precisely the impact of DCP2 could be in the changed circumstances.

DCP2 comes at a most opportune time for India, as the country is engaged in significantly stepping up investment in health and considering new initiatives. Therefore, it would be legitimate to expect that its valuable inputs would be appropriately utilized in allocating resources and designing interventions. However, DCPP needs to be regarded as an ongoing process for updating, widening, and deepening our knowledge and understanding of the public health issues of developing countries. In that role it could make a significant contribution to raising public awareness and improving the quality of decisionmaking on health issues. What DCP2 is attempting to do is to widely broadcast the seeds of knowledge—where precisely these seeds germinate would depend on the conditions in each country and the donor support. It is not unlikely that this time the major impact could be in some other part of the world. Or, the seeds may lie buried in the soil for many years, sprouting when they find a favourable environment. Any effort at dissemination of knowledge is therefore never wasted—it is bound to yield results somewhere and sometime.

The success of such initiatives depends significantly on the quality and sustainability of the dissemination efforts as well as on the development of a culture of evidence-based decisionmaking optimally using the available data, analyses, and the outputs of scientific research. Unfortunately, in India, as in many developing countries, such a culture has not yet been well established. The use of research inputs is thus largely dependent on individual preferences. If the health ministries could be assisted to develop institutional mechanisms for regular analyses of research outputs and for continuous interaction with researchers—both for receiving research inputs and setting the research agenda—this could go a long way toward better utilization of DCPP and similar efforts. Needless to say, the benefits of better choice of interventions and better allocation of resources, as well as improved delivery of health services, could be enormous. But inculcating a culture of evidence-based decisionmaking is necessarily a slow process. It requires many such initiatives, sustained efforts at dissemination, and above all strengthening the institutional arrangements in the relevant organisations.