Three years ago, in July 2019 Dr. Madhukar Pai, Associate Director, McGill International TB Centre in Canada wrote an article on "Failures of Global Health". In this article he had written:
In global health, we love to talk about success stories and publish interventions that seem to work. Eradication of smallpox, dramatic decline in polio incidence, reduction in child mortality, etc. But we also know global health deals with huge, complex, challenges. And involves several agencies and stakeholders with their own agendas and political instruments. So, failure is guaranteed. Failure is a powerful tool for learning, and we can always learn from failed interventions and projects.Then Pai went on to list some of the major failures in Global Health: "I do not see a similar openness about failure in the global health arena. To be sure they are discussed in hushed tones in the corridors of global health agencies in Geneva, New York and Seattle, but not quite publicly, in a way that facilitates learning."
Background
The Failure of Leprosy Elimination in India?
Point number 9 on Pai's list of Global Health failures is about leprosy control in India. He says that it was a failure because, "In 2005, India declared leprosy to be eliminated and scaled-back on its leprosy programmes. Today, according to WHO, India harbors 60 percent of the world’s cases, with more than 100,000 new diagnoses each year." He links his judgement on this point to an article from New York Times, "In India, a Renewed Fight Against Leprosy - Health workers thought they had vanquished the disease in 2005. But it lived on, cloaked in stigma and medical mystery."I believe that this is an unjust and superficial judgement about the leprosy services in India and its achievements. The "failure" in this case, if we can call it that, should be attributed to the World Health Organisation (WHO), which had set up the "Leprosy Elimination Goal - to reduce the prevalence of leprosy to less than 1 per 10,000 population by the year 2000".
Declaration of "Global Leprosy Elimination" did lead to premature closure of many leprosy programmes around the world, but fortunately not in India.
WHO's Leprosy Elimination Goal
The goal of "Eliminating leprosy as a public health problem by the year 2000" was decided by the World Health Assembly (WHA) in May 1991. This goal was aimed at a reduction of leprosy-prevalence to less than 1 case per 10,000 population and was not aimed at reducing the incidence of leprosy (number of new cases). Thus, in this goal, the word "elimination" did not mean how ordinary people understand this term. Everyone involved in setting up the "elimination goal" knew that it was not possible to actually "eliminate" leprosy in the sense of "not having any new cases of the disease".What was the rationale behind the decision of setting up this goal? The official reason was that if we could reduce the prevalence of leprosy in a population, the pool of infected persons would decrease and gradually the disease incidence will also decline. People and organisations working in leprosy control such as ILEP had opposed the "elimination goal" but were over-ruled (some of those discussions never really stopped and even today continue in some form on LML, 30 years after the decision of WHA).
Need for the Leprosy Elimination Goal
International Pressure to Reach the Leprosy Elimination Goal
Fixing international targets and goals can motivate governments and people but it also has some side-effects. For example, for the leprosy elimination goal, once the target was fixed, there was a lot of pressure on countries to reach the goal. If a country did not reach the goal then this meant that their programme was not good or their health staff were not working properly. On the other hand, there were insufficient discussions about the strategy itself, that reducing the numbers in high endemic areas within that period was not feasible because the other instruments to control leprosy (such as a simple serological test for diagnosis or a vaccine for its prevention) were missing.I remember the press-conference during WHA in Geneva in 2005, during which the announcement about "elimination of leprosy as a public health problem in India" was made as a triumph of the global health.
Impact of the Leprosy Elimination Goal
This leads us to the question of the need for goal-setting and international pressure for reaching numerical targets. When your country is lagging behind in reaching an international target, what happens to its health workers? The answer is easy to guess - if they do not show the required impact on the disease condition in their work areas, they will be labelled as a bad workers and their programme will be called a badly-run programme, without looking at the real situation on the ground. So what are the options for them? In many leprosy programmes across the world, when their new cases did not decrease, many of them stopped registering new cases and therefore, manipulated their data.
For example, at the African Leprosy Congress held in Johannesburg in 2005, it had come out that Tanzania which had apparently reached the elimination goal in 2000, had actually manipulated its data for achieving the goal and the actual number of cases was still high.
Failure of Alma Ata Declaration
Pai's list of failures of global health also includes the failure of the Alma Ata declaration and the goal of "Health for all by the year 2000". In his article, he had written that, "Failure to deliver on the Alma-Ata declaration: Despite the 1978 Alma Ata declaration on "Health For All by 2000", nearly half the world's population lacks access to essential health services."Alma Ata declaration on the Primary Health Care in 1978 with its goal of "Health for All by the year 2000" was one of the biggest utopias which has motivated and mobilised the health activists all over the world for almost five decades. Even today, the echoes of that call continue to reverberate among us. I think that a summary judgement that the goal of Health for All was a failure, does not take into account the impact it had and continues to have even today, for example its influence on the discussions about the Universal Access to Health.
Fifteen years ago, I had some opportunities of talking about Alma Ata with Dr Halfdan Mahler, who was the director general of WHO during the Alma Ata conference and one of its main inspiring figures. Dr Mahler, originally from Denmark, had been working in the TB programme in India, before taking up the role with WHO (in the picture below, from left - Hani Sareg/Egypt, Armando/Brazil, I and Dr Mahler in Geneva during a World Health Assembly).
Some Achievements of Alma Ata Declaration
(2) For 30 years, I was involved in Community- based Rehabilitation (CBR) programmes (also known as Community-Based Inclusive Development or CBID) aimed at persons with disabilities in rural areas of lesser developed countries. The CBR approach was a part of the Alma Ata dream, which had developed independently because PHC approach was struggling for its own implementation. CBR also had a positive impact on thousands of lives of persons with disabilities and their families all over the world.
(3) Another related programme, which was inspired from Alma Ata and has been finally realised in the past couple of years is that of Priority Assistive Products list, which brings assistive technology to persons with disabilities and elderly persons.
Impact of Other Factors
I remember many discussions in People's Health Movement during which one reason had come up repeatedly for not having achieved a full primary health care (PHC) services approach across the countries - the decision by UNICEF to implement selected elements of child care because they felt that countries did not have sufficient resources for a full implementation of the PHC approach. Looking back, I don't think that UNICEF was to be blamed because in any case, the idea of providing free primary health care to everyone everywhere was an impossible dream in a world which was controlled by forces that did not see this as important or feasible.
During the debt crisis of the 1990s, the International Monetary Fund (IMF) and the World Bank, by promoting austerity policies, had hammered a big nail in the PHC's coffin. Since then, over the last 30 years, looking at health services purely in terms of numerical calculations of costs-benefits, cost-cutting and privatisation across countries, including those which had a good model of universal health care such as UK and Italy, has further taken us away from the Alma Ata trajectory.
A second Alma Ata conference was held in October 2018, which agained called for universal health coverage and sustainable development goals. However, I doubt that it is going to stimulate the dreams of activists around the world like the Alma Ata declaration had done in 1977. This may be also because today we live in a different world, a world of climate change, AI and internet, where new goals are set and forgotten all the time. The Millennium Goals have gone by, the Sustainable Development Goals are coming and setting international goals is a business strategy and not an exercise in idealism.