Expert Essays

Sir George Alleyne's Essay  |  Mr. Rajiv Misra's Essay

The richness and the promise of the Disease Control Priorities in Developing Countries, second edition

by Sir George Alleyne, Director Emeritus, Pan American Health Organization

I was elected Director of the Pan American Health Organization and Regional Director for the World Health Organization's Regional Office for the Americas in September 1994 to begin my first term in February 1995. Part of my preparation for assuming office was to read not only such managerial texts as might show me the pitfalls I should avoid in restructuring the Secretariat, but to read and reread the World Bank's 1993 Report Investing in Health , and selective parts of its progenitor, Disease Control Priorities in Developing Countries (DCP1). I was impressed then that these publications provided much sensible guidance on the approaches I could take for the Organization's technical cooperation with countries as they sought to improve population health. They would also inform my own advocacy for the kinds of health data and data analysis needed to enhance good public health practice.

I was more than comforted by the view put forward in these publications that expenditure on health was indeed an investment-one that would be instrumental for a country's economic growth and its human development. Indeed, those two publications, plus the UNDP Human Development Report of 1990 in which the concept of a Human Development Index was brilliantly conceived buy Mahbub ul Haq and Amartya Sen were to me three of the most important works for health professionals at the beginning of the last decade.

I was therefore pleased and flattered to be asked by Dean Jamison and Prabhat Jha to be one of the editors of a successor volume to DCP1. I confess that initially I had an oft-voiced concern that the book would be directed to economists and be a paean to the primacy of cost-effectiveness as the only tool to be used for priority setting in the low and middle income countries (LMIC) of the world. I was also concerned that there might be such a focus on Africa that I would find little of relevance to the countries of Latin America and the Caribbean that I knew best.

Happily these fears were not realized and I was convinced by argument and practice that there would be a good balance with presentation and analysis of the epidemiology and social correlates of the health problems as a prerequisite for determining the cost effectiveness of the relevant interventions. It became obvious that this work would have salience for several workers and audiences who have stake in health at the individual and population levels all over the world. The list of topics addressed is considerably longer than in DCP1 and was crafted in such a manner that it does represent those that that are indeed most pressing as the LMIC strive to improve the health of their people. The reader will be struck at once by the bold and substantiated assertion that it is possible to achieve significant health improvement in these countries at their current stage of economic development provided good choices are made. Given the emphasis we have placed on equity in health in the Americas , it is particularly pleasing to note that the issue of health inequities, their determinants and the means to address them is a current that runs strongly through this book.

This is not the place to review the book's contents, but it is noteworthy and praiseworthy that the second edition of Disease Control Priorities in Developing Countries (DCP2) incorporates issues that are in a sense unconventional and innovative for a work on health priorities in developing countries. For example, the value of information for establishing priorities must be intuitively obvious and is repeated almost religiously, but here the clear distinction is made among data, information and knowledge and there is a bold effort to actually measure the cost of the information needed to address the health problems of developing countries as well as the cost effectiveness of a specific local information initiative.

Treatment of the communicable diseases that affect LMIC are treated exhaustively, paying due attention to the neglected helminths, malaria, tuberculosis and the scourge of HIV/AIDS, giving proper emphasis to the non-homogeneity of the epidemic even in the LMIC and therefore the need for tailored interventions. However, one of the loud messages is that the train of the noncommunicable diseases (NCDs) and particularly cardiovascular diseases (CVD) (primarily ischemic heart disease, stroke and congestive cardiac failure) is approaching at a pace that calls for urgent attention. There is detailed analysis of the major risk factors for CVD: tobacco use, blood pressure, blood lipids, physical inactivity, overweight and obesity and diabetes. It is demonstrated clearly that there are cost effective pharmacologic as well as non-pharmacologic interventions to be used at the individual as well as at the population level. There is no doubt that the most cost effective intervention for the prevention of CVD at the population level is increase in tobacco taxes. Other interventions include regulations for altering the composition of dietary fat with reduction in the saturated as well as the trans fats, reducing sodium intake and facilitating increased physical activity. These are all measures that the LMIC can adopt now.

I believe that DCP2 has managed to avoid the sterile and tired differentiation of programs as being vertical or horizontal and has demonstrated clearly the interconnection between them and the health systems necessary to make them operative, as well as examining those inputs that make the systems perform better and represent best value. The demonstration that district surgery is highly cost effective is one of the many nuggets of the book.

The bold attempt to determine cost effectiveness for such a wide spectrum of interventions and the honesty of displaying the ranges of such effectiveness may attract criticism. But careful reading will make it clear that the analyses are anything but prescriptive and cost effectiveness represents a very powerful, but yet one of the tools to be used in establishing priorities for resource allocation. Readers will also find that many of the cost effective analyses do give the relative merits of various interventions for the same specific condition.

There is honest effort to address the research and development needs for reduction of the disease burden of the LMIC. The research spans the need for application in the LMIC of the various clinical and epidemiological studies that are referenced from the developed countries to the basic sciences of genomics and immunology that will be needed to develop new therapies for old and new diseases.

In the final analysis, the impact of DCP2 will depend on the extent to which policy makers understand and apply its main messages. Will there be continued use of the interventions that are proven not to be cost effective, ignoring those that are already available and are cost effective? Even with the limited resources, will health expenditure go towards to interventions that are glamorous but highly cost ineffective and are adopted as a result of propaganda and promotion from the developed countries? The difficulty will be compounded because the adoption of cost effective interventions may mean abandoning those that are not.

Thus the major task post publication of the book will be the marketing of its contents and messages with the most important one being that the choice of intervention does matter. This task starts with an advantage in that DCP2 engaged hundreds of scientists from all over the world and these are likely to be advocates, but the effort cannot be left to passive endorsements of the findings. Unless there is aggressive marketing to policy makers and seeking to have public policy changed by engaging the scientific community, the media and other interested social actors that are influential locally, the tremendous effort that has gone into this work will not have been maximally successful. The auguries are good in that in the development of the book the editors had the advice of a very distinguished Advisory Committee and given the involvement of partners such as the World Bank, the World Health Organization, the National Institutes of Health, and the Bill & Melinda Gates Foundation coupled with the oversight of a very accomplished marketing and dissemination body there is every indication that the key messages will be heard all over the world and their application will make a difference.

My strong recommendation that this book be widely read and inform policy stems not only from my close involvement with it as an editor, but also my experience with health development in a wide range of countries has strengthened my view of its importance. I wish to see a variety of audiences reading it. I wish to see it lose its pristine newness as it is used and reused, read and reread to get to the kernel of the critical messages it contains. I would urge that the many important partners that have accompanied the development of this book, such as the InterAcademy Medical Panel (IAMP) be active and committed supporters of its thrust and its messages. It is only in this way that we will create a community to take advantage of the richness and promise that is DCP2.

George Alleyne
March 7, 2006

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Disease Control Priorities in Developing Countries, second edition Perspective of a Policymaker

by Mr. Rajiv Misra, former Secretary of Health, India

I have been privileged to be closely associated with the application of the principles for priority setting of Disease Control Priorities in Developing Countries (DCP1) in India in collaboration with the World Bank in the early nineties. Having personally experienced its many advantages, I have indeed high expectations from the second edition (DCP2) to contribute towards the improvement of the quality of decision making in health.

DCP2 seeks to address a wide audience: policymakers, health professionals, researchers, media, and the public at large. But the main target group has to be the policy- makers, as they are in a position to make the maximum difference. In essence, DCP2, its predecessor DCP1, and all other similar efforts have sought to encourage evidence-based and rational decisions by making available the relevant knowledge and evidence. This is critical in resource-constrained environments as every dollar misallocated or misspent could mean a lost opportunity for saving a life.

Unfortunately, the progress has been difficult and slow due not only to the complexity of challenges but also because governments generally do not make decisions solely on rational and public welfare considerations: political concerns, special interests, and personal prejudices exert a major influence. And this is even truer for developing societies with poor public awareness and accountability. On top of this, the relevant information and analyses needed for a decision on merits is often unavailable even where the political leadership has an open mind. The problem gets further compounded by the political leadership often having a short-term perspective–desiring visible results before the next elections.

DCP2 is a major step forward in pulling together and analyzing the extensive body of knowledge gained so far and placing it before the decision-makers for meeting the huge health challenges facing the developing countries. However, if the publication is to make a significant difference, it would need a change in the decision-making culture . This is by no means an easy task. Besides the policymakers and the health establishments in the developing countries, we need to educate the people at large to empower them to hold their governments to account when interventions do not respond to their needs. The widest dissemination of DCP2 messages through partnerships with the civil society is thus the key to successful translation of the new knowledge into improved allocation and utilization of available resources.

DCP2 makes a major contribution by updating and refining burden of diseases (BOD) and cost-effectiveness (CE) estimates. Notwithstanding its wider mandate, its core strength continues to be the application of economic tools to public health, providing quantifiable information on BOD and cost-effectiveness to facilitate evidence-based decisions on resource allocation and choice of interventions. While use of this information should be a major input for decision making, DCP2 itself recognizes that it cannot be the sole criterion; Chapter 2, which summarizes CE findings, clarifies that "there is no one-dimensional economic criterion that interventions must attain to be declared economically fit, and cost-effectiveness plays the more useful function of informing the tradeoffs that policymakers are forced to make when investing in a portfolio of health interventions." Besides, political leadership must take humanitarian concerns into account along with public health and economic criteria. A citizen does not have a choice in the nature of his/her ailment, and even though the intervention required might not be cost-effective, that in no way diminishes either his/her need or the right to receive treatment. This does not in any way reduce the value of CE. For some health conditions, particularly noncommunicable diseases (NCDs), the interventions of choice may become prevention and control of risk factors that are often highly cost-effective. Also, the high cost of treatment for such conditions highlights the need for continuing emphasis on developing more cost-effective tools.

Recognizing that mobilization and efficient utilization of resources is just as important as their rational allocation, DCP2 broadened its mandate to cover issues related to health systems and delivery of interventions. Although much useful information has been gathered, the volume makes few definitive recommendations. Since DCP2 primarily reviewed existing literature, the inadequacy of available research seems to have become a major constraint. Chapter 3 admits clearly that "the current body of knowledge represents a largely ad hoc and disjointed collection of facts, figures and points of view." In many areas not enough is known, and considering the multiplicity of factors influencing performance and the diversity of situations, much more work is obviously required before arriving at many conclusions. This is a disappointing outcome, as the developing countries needed guidance on these complex issues, perhaps even more than on priority setting. However, this effort could still be useful in two ways:

  1. A wealth of information on international experience has been pulled together, which should help better informed decisions.
  2. DCP2 clearly sets out the agenda for further work in the inadequately researched areas.

I earnestly hope that with sustained effort the current gaps in knowledge would be overcome, and a list of "best policies and practices" can join the list of "best buys" to guide policy makers. That will clearly be a huge contribution towards improving the quality of decision-making.

There are a few areas of concern to the developing countries that I feel could have been better addressed.

  1. Chapter 1 brings out in some detail the economic benefits of good health. It also recognizes that poor health "is a source of grief and misery, and it is a sharp brake on economic growth and poverty reduction"; yet it does not fully analyse the close nexus between poverty and poor health and the critical role that investments in health could play in poverty alleviation. This is rather unfortunate because, in a global environment of heightened concern for poverty, the failure to put health in the forefront of poverty elimination strategies could undermine resource allocations to this sector. Further, the chapter does not highlight the major contribution of medical expenses on the aggravation of poverty, which could again divert attention from the importance of providing financial risk protection to the poor.
  2. Redressing inequity in health is a core concern for the developing countries, and I think DCP2 does not articulate it sufficiently. Promotion of equity is not just a moral and political imperative, it needs to be an essential part of the strategy to improve health outcomes in poor countries. Chapter 1 cites the example of China , Costa Rica , Cuba , Sri Lanka , and Kerala state in India to "conclusively show that dramatic improvements in health can occur without high or rapidly growing incomes." I believe that emphasis on equity is one common element clearly identified with each of these examples.
  3. While the growing burden of NCDs in developing countries and the huge demands that would make on their weak health systems has been recognized, no clear recommendations have emerged on how the necessary strengthening of health systems could be carried out in resource-constrained countries. Further, the document doesn't articulate clearly that both the choice of intervention and the cost of treatment depend largely on the stage at which the disease and risk factors are identified and treated. Some guidance on how to develop a system of early detection and treatment/referral in low-income countries would have been most helpful.
  4. In respect to mobilization of resources, DCP2 offers a rather pessimistic prognosis for low-income countries (LICs), which seems motivated by a desire for realism. But by limiting the prospect of increases in public-sector spending to just 0.5% of GDP, I wonder how any significant improvement in health outcomes can be realized. Public-sector spending includes external resources as well, and if LICs are indeed incapable of raising resources domestically, one would hope that donor agencies would be encouraged to make up the deficit.
  5. Chapter 4 settles the controversy over inadequate investment in research on diseases predominantly affecting developing countries, popularly known as the 10:90 issue, rather neatly by asserting that all research is global and new knowledge–a public good–benefits all. Admittedly, there is increasing attention to diseases that predominantly afflict the poor, thanks to the efforts of the Global Forum for Health Research and the reports that preceded it, e.g. the Commission on Health Research and Development and the Ad Hoc Committee on Future Intervention Options. But it needs to be clarified that only knowledge unencumbered by intellectual property rights could be considered a public good. Much of the new knowledge is generated commercially and is not in the public domain. Attempts have been made in the past to restrict access even to basic research, such as the sequencing of the human genome. In this context, it would have been useful if the critical role of the public sector, including academic institutions and charitable foundations, was emphasized.

The above concerns do not in any way detract from DCP2's excellence and its great potential for contributing to the diffusion of knowledge that Chapter 1 rightly holds as the key to improvement in health outcomes. Both the Disease Control Priorities Project Team and the organizations that supported the effort deserve our gratitude for bringing out a document that could significantly add to our understanding and knowledge of health-related issues and guide us in facing the great challenges ahead. However, DCP2 should not be regarded as a one-time effort: it is a part of a continuing process to develop and disseminate knowledge on health. This document itself lists many gaps in our knowledge that require an urgent research response. I firmly believe that we will need many more DCPs to reach the stated goal of universal application of available knowledge, which alone can remove the unacceptable disparities in global health.

Rajiv Misra
April 2006

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