The Ministers’ magic moment: a cookbook for disease control
First, take 900 scientists and health experts from around the world. Second, identify the world’s most cost-effective health interventions. Third, tell the world. Fourth, over to you, Ministers: turn them into action.
SUMMARY: Dean Jamison, Editor-in-Chief of the extraordinary Disease Control Priorities Project, recently launched in Beijing, tells RealHealthNews the back-story and discusses some recommendations.
RHN: How long has it taken to produce this massive set of recommendations, the second Disease Control Priorities Project, DCP2?
DJ: We’ve been working away on this for about four years. 700-900 people were involved, with about 350 chapter co-authors. DCP1 had about 100 chapter co-authors.
RHN: So what did you learn from the previous experience that makes a distinction between DCP2 and the first DCP1 in 1990? What’s changed?
DJ: I probably learned less than I should have, but others learned more! The world still isn’t completely aware of the degree to which the epidemiological transition has taken place in low- and middle-income countries, and how noncommunicable diseases (NCDs) and injuries are dominant in the disease profiles in so many of them.
People were even less aware in 1990, though there were a couple of indications that pointed to it. What was not known in 1990 was what affordable effective responses there might be to coronary disease, stroke, pulmonary disease, and various forms of cancers.
Looking back on it I’d say there were a couple of things that were most important, and a rather separate set of things around the World Development Report 1993, that drew heavily on DCP1.
One thing we learned was that if you look around hard enough, there is at least a short list of moderately cost-effective things to do around prevention and management of NCDs. So we came up with I think a constructive technical agenda for an affordable response on something like a population-wide basis in a country like China, for example. Obviously in China they can and do take every technological breakthrough from Germany, France and the US and apply that in their leading hospitals in Shanghai and Beijing, and they do it very well, but given the costs that can serve maybe a couple of percent of the Chinese population. So the question is what can they do for the whole population with the resources available there? So this was a set of technical, partial answers to that question.
RHN: And this time you’ve looked at more cross-cutting issues, haven’t you?
DJ: Yes. There have been a couple of differences in mandate and style. I’d planned when we did DCP1 that there’d be a second, cross-cutting volume, looking at the delivery systems for interventions, packages of interventions – spending more time on interventions that themselves addressed several major diseases, like control of smoking, and on major delivery systems. We had a little bit in DCP1 but it was not a serious treatment. So that just never happened.
In DCP2, our sponsors – particularly the World Bank but also WHO – expressed a very strong view that that not be allowed to slip this time. So we put that kind of material in.
RHN: That explains for example the large amount of material in DCP2 on health systems, for example?
DJ: That’s right. And risk factors, and to a lesser extent consequences of disease rehabilitation like visual or physical impairment, whatever the origin of the condition; and one step back from that the more standard health systems issues, the public health side, clinical services and internal and external finance.
RHN: What about the impact of studies like these? What lessons did you learn from DCP1 about the obstacles to implementation? Because there are plenty of conclusions here that are wonderfully comprehensive and eminently sensible, but they are not all entirely new; and it seems that improving the health of the poor is just as difficult as it always was. So what exactly are we working against?
DJ: I’ll give you my views on that. As you say, many of the main conclusions are frankly, obvious. I think, personally, that the current movement in right-wing America and left-wing Europe towards a focus on systemic reform has not been constructive.
RHN: Incidentally, by “left-wing Europe” do you mean the UK?
DJ: I mean the public health schools. I think of the public health left as a somewhat global community but a little bit more evident in Europe.
RHN: You don’t mean Tony Blair’s reforms of the National Health System in the UK…
DJ: No. From the American point of view Margaret Thatcher’s reforms of health were solidly left wing. She was not going to introduce user fees at the point of service for a universally financed public health-care system. From an American point of view that’s just wonderfully refreshing!
Conservative economists in say US and British academia and particularly the international financial institutions would view two things as inappropriate in state health-care financing. One is to do as the British and French do and have the state pay for purely private clinical services for well-to-do people who are perfectly willing and able to pay. Why should the state pay for a rich guy's broken leg to be fixed? There are some good answers to that, but it’s not completely obvious. The conservative position that dominates the World Bank is that the state should never pay for that, but rather focus on the poor.
So my personal answer to your question, why have things gone more slowly than they might have gone, I think it’s too much of an attempt to focus things on the poor. And too much focus on systems reform as opposed to getting things done, and strengthening systems as they learn by doing, exercising themselves in credibly achieving something. And finally we haven’t put enough money into it.
RHN: I was struck immediately by a couple of things as I started to read Priorities in Health. One was the use of the word “technical”. I imagined that would mean the products of the pharmaceutical industry and biological research – but you use the term extremely widely, so far as to include things like new cadres of health workers, what used to be called “barefoot doctors”; and that the first places that are mentioned as great successes in health are the darlings of the left: Sri Lanka, Kerala in India, and Cuba. So I was wondering if you were using the word “technical” to embrace positions that had been ideological before?
DJ: I think we may have been mistaken in communication in using the word “technical” in the way economists use it, which is exactly in the comprehensive way that you’ve described. A technical change can be a change in the way of managing structures. It can be the epidemiological knowledge underpinning public sector decisions to influence smoking. All that is technical. And in addition of course the vaccines and drugs and so on. So whatever the mix is of say oral rehydration therapy (ORT) or the kinds of organizational changes or systems to deliver ORT to a large population. And the diffusions of that knowledge of what to do and how to do it has proceeded very slowly in some parts of the world and faster in others.
RHN: Let me ask you about the use of the word “knowledge”. If you are going to argue successfully against those with other positions – for example in the Bank, as you’ve just described – you need a very strong evidence base. So how strong is the evidence base for the recommendations that are being made in DCP2?
DJ: It varies quite a bit. When we talk about policy we have to talk from evidence accumulated at this point in time, from many sources, from randomized clinical trials to the experience of clinicians and public health officials. And the task as I see it that we set ourselves was to make the best available use of evidence that’s sometimes quite good - and often quite poor – or evidence that’s good but originates in one part of the world and we are trying to apply it to a very different part of the world.
So in health care finance, for example, we know a lot about that in high-income countries, and the lessons are reasonably clear, and for an upper-middle-income country like Mexico or Brazil it's probably pretty relevant. But for an India or China I would personally judge that that evidence is much less strong. To me, it doesn’t mean that we are in an evidence-free world; it’s just that there is nothing quite as decisive as a clinical trial.
RHN: And it leads to an argument that more research is needed in these areas.
DJ: I think so. For example – I’ve discussed this at length with the authors of our AIDS chapter – the AIDS community and the people who finance their work, both the prevention part of it and now the treatment part, are accumulating knowledge so slowly! This is absolutely incredible given the importance of the epidemic! There are opportunity costs for the interventions like mass treatment with ARVs that say PEPFAR is paying for, or the Global Fund to fight AIDS, Tuberculosis and Malaria. Richard Feachem [the current Director of the Global Fund] doesn’t see it as his mandate to do research, as far as I know.
RHN: So what needs to be done there to accumulate knowledge more quickly?
DJ: One thing is to look at a lot more variety of things we do, including different drugs and combinations; and a lot more resources, not necessarily into randomized clinical trials but into systematic learning from the varied implementation.
RHN: I see – so you’re saying varying the implementation, and run studies alongside.
DJ: I’ve talked to the people in the academic world here financed by the Bush administration through the US Centers for Disease Control (CDC), on things like early mother-to-child transmission [of HIV]. They had the sharpest of instructions from the CDC – not that CDC wanted to pass on these instructions but the legislation was clear – that they were not to be doing any evaluation research. This was not meant to fund the careers of pointy-headed academics; this was meant to fund real people. That was the message.
RHN: Developing-country scientists have complained about the lack of a research culture amongst their policy-makers – do you think it’s also lacking in the North?
DJ: Well I think it often is, and in the US today we are seeing an extreme version of it. And it comes from the top way down, because it shapes the legislation and the executive. We see a very anti-scientist and anti-scientific attitude here. But I don’t think that’s typical of the North. I hope evidence makes a difference to say UK Chancellor Gordon Brown!
RHN: Let’s come to some of the central points of DCP2. You say much more can be done with existing resources if knowledge of cost-effective interventions were applied more fully; and resources are wasted when wrong interventions are applied. Can you give us some examples of that?
DJ: We’ve probably cast that too broadly. For many low-income countries, that’s not a point I’d want to emphasize. It’s a message more for middle-income countries. The different kinds of evidence around it, for example, concern the large tertiary facilities [major hospitals] that aren’t buying very much health. The question is how far those resources can be politically redirected. In one country, for example, they kept the hospital – but made three of the wards into TB wards. Well that may have been slightly more expensive than having a district hospital, but given where they started from it was an awful lot better. It was an intelligent response.
RHN: Let’s take your “million dollar” table – the disability-adjusted life years (DALYs) that you could save for a million dollars with different interventions. First a technical question – are these just the direct costs or do they take into account the economic benefit of better health, which you discuss elsewhere in the report?
DJ: These are the direct costs.
RHN: So there is also an extra benefit.
DJ: Yes. And they are a substantial multiple of costs. But I go round saying that and no one believes it very much, so we don’t try to stress it!
RHN: If we take the top few interventions from your table, immunization is number one again; then taxing tobacco; artemisinin combination therapies for malaria; caring for infants under 28 days; treating sexually transmitted infections to interrupt HIV transmission; and a heart attack combo pill.
And then you have another list of top interventions, which includes those plus reducing HIV transmission from mothers; condoms; quality incentives for health providers; surgical capacity at district hospitals; expanding resources for infectious diseases in developing countries; and a publicly financed clinical care package for middle-income countries.
I’m skimming through these. But let me ask you: what message in DCP2 do you think is likely to have the greatest impact – to make people sit up and change, and do something different?
DJ: It’s difficult to separate what I think should happen from what likely could! Some of the things that could happen, I think, include a lot more attention to surgery.
RHN: When you say “could”, you mean you think it’s quite likely to happen given the social and political circumstances.
DJ: Yes, over a period of 5-10 years. This affects a lot of people’s lives. There are lot of surgical interventions that are fairly decisive. If systems do surgery well for trauma and obstructed labour, common things like hernias in males and so on, they will get a lot of kudos and credit. There’ll be positive political feedback. But there’s been intellectual opposition. Surgery seems like very clinical medicine, the very opposite of public health. But it should be defended for what it is.
RHN: Are we talking about middle-income countries here?
DJ: No – take India, a solidly low-income country – well-trained surgeons are not enormously expensive. And it’s not enormously complicated, compared to say what I see as the complexity of, say, managing antiretrovirals. So I see that as one that will make a difference.
Then approximately one-third of deaths under age five are from the onset of labour to the first six days. People don’t focus on that very much, but there does appear to be a fair amount that can be done. So resuscitation, keeping babies warm, delivery care – there’s a series of things that are not too hard to do and not too expensive, that have been getting a lot less attention than the older under-five interventions like treatment of acute respiratory infections, immunization and malaria. They are all important, but there’s an opportunity too to help the younger age group. So that’s another area where I think there could be some changes.
RHN: Looking back to DCP1, what changes did that achieve? And what will you do to ensure that DCP2 actually creates change rather than simply knowledge?
DJ: There were a couple of lessons from DCP1. First, given the [low, US$5-10 million] cost of these intellectual, synthetic exercises, you don’t have to effect very much change to pay for the thing very quickly. That’s a very modest goal. But looking back at DCP1, if the only consequence in the real world had been to accelerate slightly the use of short-course chemotherapy for TB – and I think it did do that; in fact I think it made a pretty big difference – [it would have paid for itself]. If it increased immunization coverage by 1%, it would have paid for itself 50 times over. There really are some pretty big benefits to be had out there by doing a little bit more of the right thing.
RHN: How do you think DCP2 will be used? You have a very broad audience in mind, and it’s a massive text. But you are trying various communications techniques to make sure it gets to the right people.
DJ: Right, and that’s a huge change from the last time around. A lot of it has simply to do with money. We scrambled and scraped to get the last dollars together to publish DCP1, and that was that. This time, the Gates Foundation, which provided half the cost of preparation of DCP2, has a grant for US$4 million to the Population Reference Bureau to disseminate this thing. To someone like me that looks like a hell of a lot of money! But they have a series of methods and are being very serious about the website.
RHN: It’s one thing to have good communications, but it’s another to think about the whole network of interests, affecting politicians and policy-makers, within which you are trying to influence opinion. Don’t we need to understand those interests as much as we need to understand health?
DJ: I think it would be helpful. But it’s not something that I think economists or doctors or scientists have a comparative advantage in doing. It gets much more particular than the epidemiological environments of countries. So if you take Washington DC, the manipulation of political interests now seems to be heavily influenced by money. I expect that’s to some extent true everywhere, but in Washington today it’s unusually true.
So in terms of constructively manipulating political behaviour, what counts is people with money – people like Bill Gates. The Gates Foundation asked us about these kinds of things. We thought about it, talked about it, and they said that sounds awfully amateur to us! We prepared some dissemination plans and they thought them frankly fairly dumb! And they were probably right, that we didn’t have a sense of how to influence things.
Let me give you one example where the Gates Foundation is using both ideas and money. Many things influence behaviour, and ideas are only one. Shortly after Rick Klausner became head of Global Health at Gates, he and I spent three or four hours together. What was clearly on his mind was essentially the question you asked. He wasn’t unused to the political environment – he’d been Director of the National Cancer Institute – but he said he’d now been thrust into a position where he's spending a lot of time interacting with sympathetic and unsympathetic politicians, political officials and legislative aids.
And there’s an overwhelming line that’s coming back to me, said Rick Klausner, that we are loving warm-hearted Republicans, compassionate, we want to help, health in Africa is enormously important to our hearts and we suspect even to out constituents. More money would be the first thing we’d want to give. “But it’s just pissing money down a rat-hole!”
The politicians were telling him that it’s all being done by the public sector which was either incompetent or corrupt or both, so the money ends up in Swiss banks, or wasted, or spent on a few high-priced consultancies flying business class on Air Afrique with three glasses of champagne. And the money goes to them, not the very worthy poor people whom we’d love to help. But we don’t know how, and you don’t know how.
Well you can think that that’s all bullshit, that they don’t want to spend the money anyway, or that maybe there’s some truth in that. I think it’s a combination of both.
So one of the things that Rick and I decided we wanted to do was to put together a set of well documented, intellectually sound, arguments on the other side. Advocacy, but honest, well-informed advocacy, on the other side. And what we’ve been doing in DCP2, which by then was under way for a year, was to ask all our authors to identify examples of success, and try to figure out why [they’d worked].
So we asked if you are dealing with cataract surgery, or acute myocardial infarction, and if you’ve got some suggestions about how that might be done, please point to those places around the world where that has been done. So in a backward kind of way that would answer the kind of question you were raising.
Well the authors didn’t want to think about that very much, but Rick said let’s pursue that much harder. We tried to identify as many cases as we could of interventions with several characteristics: one, they addressed a major health problem with interventions that were at least somewhat cost-effective; two, that they’d gone to substantial scale; third that they’d lasted a long time so there was some degree of sustainability; and fourth that there had been some credible evaluations of how it worked.
So we ended up with 17 case studies, and published them as the book “Millions Saved” [see box]. I gather that it ’s been quite an influential book in Washington.
So I think the ideas side of changing the politics – it’s a very different approach, case studies of what worked – can be complementary to what you want to be pushing against.
But I don’t think we are going to make a big dent in all that. My personal aspirations on this are long term. Graduate students. Doctors aged 36 from Mali getting their Masters in Public Health from Johns Hopkins, who go back and in six or seven years might be Minister of Health. Different people associated with the project have a different vision of impact. But my vision is that over time, it will change things.
RHN: On health systems, DCP2 says: “The body of knowledge on health systems represents a largely ad hoc and disjointed collection of facts, figures, and points of view, making confident recommendations relevant to strengthening health systems difficult.” So it’s an argument for more studies.
DJ: Absolutely. And in terms of the world trying to learn something, the amount of money going in to health systems research in developing countries, as far as I can see, is really trivial.
RHN: The report seems to be equivocal on user fees. It’s saying they need to be looked at in a very particular and local fashion. They may be good in one place and bad in another, in contrast with ideological positions that would say they were always good or always bad.
DJ: I had many long conversations with the authors of the finance chapter, who were all World Bank staff! First off they didn’t want to write about user fees because they didn’t think we knew enough. I said the Bank’s been taking positions on this for 15 years, do you think we haven’t learned anything? They said it’s controversial. I said, so what! So I was going to write about it in the first chapter, from my reading of the literature.
Apparently this precipitated quite a large discussion within the World Bank. I said you’re arguing from the Bank’s documents, but I can argue from documents for universal public finance for certain basic health services, against user fees. So they said sometimes we need them. So when do we need them and who will be charged?
Then we went back to the World Development Report that’s just come out on improving delivery of services to the poor, which has been influential in the Bank and was written by an unusually right-wing collection of authors – even within the World Bank context.
It’s interesting on user fees. First off, it’s very complex, with an eightfold algorithm that’s far too complicated to make a difference. Then they have a “crate”, not a box, on the PROGRESA programme in Mexico where you pay poor people if their children are immunized and in school. All the evaluations are saying that that really works. Those are negative user fees. So what I get out of the report is that we need negative user fees, conditional cash transfers, which I also support on the evidence in Mexico.
Our finance chapter is sort of against user fees, with lots of exceptions. I think chapter one takes the position that we are trying to move towards universal public finance, and that that clearly means, when you don’t have much money in the public pot, that not much will be financed – but it will be financed for everyone.
RHN: Yes – it does seem to be a very pro-public finance document.
DJ: Well I think that’s what the evidence in the high-income countries strongly suggests, and the early evidence from places like China and Kerala. If it reads like that, good, because that was intentional!
RHN: This won’t create an immune reaction amongst the political right?
DJ: Well the World Development Report 1993, which was much more muted on this, still gets right-wing economists up and going for its “woolly-minded soft-headed liberalism”. So yes I expect it will.
RW: If just one thing came out of DCP2, what would you like it to be?
DJ: I think it would really ramp up the degree of effort that goes into understanding how to prevent and treat the major noncommunicable diseases, in low-resource countries. I don’t think we are putting anything like the right resources into that now. I think the resources are too focused on high-tech solutions.
For example, I was stunned at the cost-effectiveness of treatment of acute myocardial infarction – and there are a lot of heart attacks. So how do you get it done? We need the investments in learning about how to make that kind of knowledge relevant in a country like India. They would need a large scale clinical trial with say 40 Indian medical schools and 200 Indian researchers, trying out different ways of getting that done in practice in Indian clinics and hospitals. But the agenda isn’t going anywhere as far as I can see. Maybe this book isn’t going to help it along, but I hope it does.
The poor state of health systems research
According to DCP2:
Evidence on most health system reforms – for example, hospital autonomy reforms and decentralization – is inadequate to draw [useful] conclusions.
Few studies relate a reform to health outcomes. Even evidence on intermediate outcome measures, such as costs and quality of service provision, is often lacking.
Virtually no information is available about the costs of strengthening [health system] capacity or the effectiveness of different approaches to capacity strengthening, even though the lack of system capacity is widely noted.
Evidence is largely lacking on the characteristics of delivery strategies capable of achieving and maintaining high coverage for specific interventions in various epidemiological, health system, and cultural contexts.
Evidence is lacking on what types of governance and institutional arrangements will support the achievement of widespread health improvements, especially for the poorest members of society.
DCP2: the main recommendations
Half of all deaths (including stillbirths) of children under age five occur at ages under 28 days, but little attention has been paid to this age group. Cost-effective interventions exist.
Treatment of HIV-positive mothers, treatment of sexually transmitted infections, free distribution of condoms, and other interventions can cost-effectively interrupt HIV transmission. These preventive interventions continue to receive inadequate attention.
Controlling tobacco use, particularly through taxation, is feasible in developing countries and is the single most important intervention for reducing noncommunicable disease.
Lifelong medical management of risk factors in individuals at high risk for heart attacks or strokes, using aspirin and other drugs, is cost-effective and would benefit tens of millions of individuals.
In the health system, provider incentives matter. Financial or other recognition for timely, responsive service increases the likelihood of such services.
Conversely, the use of financial incentives for the excessive or inappropriate use of drugs or diagnostic tests is an all-too-common cause of high costs – and poor health outcomes.
Having providers do a few things frequently, rather than attempting to provide diverse services, facilitates quality improvement with potentially major improvements in health outcomes.
Strengthening surgical capacity at district hospitals is likely to be cost-effective and would address broad needs.
In low-income countries, targeting the very limited public sector resources for health to control of diseases – such as TB – that particularly affect the poor would be efficient.
In middle-income countries, public finance – or publicly mandated finance – of a substantial package of clinical care for all would be equitable and efficient in meeting health needs, controlling costs, and providing financial protection to populations.
Where research is neglected
Individual chapters of DCP2 discuss R&D policy in general, and identify R&D priorities according to disease or area. Overall, the report endorses the expected priorities but concludes that research is neglected on:
tight evaluations of interventions and systems [operational research]
improving public service provision
enhancing human resources
ensuring accountability for health outcomes, funds, and medicines
ensuring a functioning central government
providing evidence for policy
epidemiology of injuries and cost-effective interventions to reduce the burden resulting from both intentional and unintentional injuries, particularly motor vehicle crashes and road and vehicle safety
major risk factors for disease in different contexts (e.g. tobacco, obesity, physical activity)
medical and surgical errors
occupational and environmental health
risk analysis and risk communication
delivery of care at different levels of the health system
performance of health systems
management of health research
reproductive and sexual health
health effects of global warming