Failures in Global Health?

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."

I think that Pai was a little superficial for at least 2 of the failures (leprosy elimination in India and the goal of health for all) on his list. I feel that it is simplistic to give summary judgements of success or failure without taking the time to go and study what had really happened and the documents from that period. IMO, such views could have been understandable in past but in the internet age, so much information is openly available, such a judgement from Pai is less defensible.

Background

During the 1990s and 2000s, I was active in the discussions about Global Health at international level, for example, in the People's Health Movement (PHM). In that period, I was collaborating regularly with the World Health Organisation (WHO) in Geneva. Around 2004-05, for a couple of years I was also the president of ILEP, the international federation of organisations fighting leprosy. Thus, I witnessed firsthand most of the things about "Health for All" and "Eliminartion of Leprosy", I am writing about in this post.

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".

The WHO goal was actually for "reducing the leprosy burden" but it was called "elimination goal" for political reasons. In 2000, WHO had declared that the elimination goal had been reached at the global level, but India was not included as a success at that time. India had managed to reduce its leprosy burden to the level of WHO's elimination goal only in 2005.

Declaration of "Global Leprosy Elimination" did lead to premature closure of many leprosy programmes around the world, but fortunately not in India.

Instead of asking about the "failure of India's leprosy programme", we should be asking - "What is the impact of setting international disease-control targets and what can we learn from the experience of WHO's Leprosy elimination goal?" I want to answer that question in this post.

I am writing this post from my memory of the events, but a lot has already been written about it, as can be seen from a simple literature search.

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

There was another reason, a more important one, for setting the Leprosy Elimination Goal. MDT, a new combination of drugs for treating leprosy was recommended by WHO Expert Committee in 1982. A review meeting organised by WHO on the progress in the implementation of MDT was held in Brazzaville (Congo) in 1990. It had shown that after 8 years of recommending and promoting MDT, globally less than 15% of the leprosy patients were being treated with it, while the remaining persons were still taking only Dapsone (in many endemic countries, the percentage was less than 5%).

I believe that this situation was linked to 2 other issues - (1) most of the leprosy programmes were being run by NGOs and missionaries, while the governments played little or no role in them; (2) the programme decisions were made by clinicians, who focused on individuals and not on the collectivity. Thus, while the WHO had been pushing for the adoption of MDT, doctors working in leprosy programmes felt that MDT administration needed their personal supervision and were hesitant to start it in rural areas where doctors were not available.

The "Elimination goal" was targeted at the governments, asking them to assume greater responsibility and, simplify and expand the use of MDT without requiring supervision of doctors and it achieved great success in reaching both these objectives - MDT coverage increased across the world and national governments took over the responsibilities for running their leprosy programmes from the NGOs and the missionaries.

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.

When it became clear that many countries like India and Brazil would not reach the elimination goal by the year 2000, there were other effects. So, under the new WHO guidelines, treatment duration was reduced, active search for new cases was stopped and countries were encouraged to quickly integrate vertical leprosy programmes into their primary health care systems. All these measures helped in reducing the identification of new cases, the numbers decreased and India could reach the goal in 2005.

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

As explained above, the "elimination goal" was actually a "reducing the disease burden goal" and its objectives were to expand MDT and to improve government run leprosy control services. The elimination goal was successful in both these objectives. Expansion of MDT had a huge impact and millions of persons could be treated effectively and a large number of complications such as disabilities were prevented. Thanks to the goal and expansion of MDT, individuals affected with leprosy could be fully treated in 6-12 months and avoid most of the complications. Finally, for the health workers leprosy was like any other disease.

Once it achieved those results, ideally WHO should have clarified it and explained to the countries that we had not eliminated leprosy, we had only reduced the disease prevalence. However, that was not possible due to political reasons. Many persons involved with this issue in WHO had also started to believe that with reduction of disease burden, the disease transmission will be interrupted and the number of new cases will start deceasing, and were very optimistic. Unfortunately that did not happen and the fall in the number of new cases over the past 20 years has been much slower. The image below shows the participants in a WHO meeting in 2005 (Dr Lee, DG of WHO is in the centre, while I am the first on the left ) to talk about the leprosy elimination goal.

Reaching the "leprosy elimination goal" had consequences. Thus, in different countries across Asia, Africa and South America, reaching the goal led to many countries to scale-down their leprosy control programmes, even when they still had many new cases. Fortunately for countries like India, Indonesia and Brazil, their health professionals knew that leprosy was still a big issue and they could continue the leprosy programmes, but for many smaller countries, especially in Africa, achieving the elimination goal led to elimination of their leprosy programmes for many years.

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. 

Unfortunately, the negative impact of the term "leprosy elimination" for this goal continues to create problems even today, because countries and health workers start beliving that do not have a significant leprosy problem.

For example, in 2016, I was involved in the evaluation of a leprosy programme in a couple of districts in central India. The evaluation showed that eleven years after reaching the WHO goal, district health officials were still confused about its meaning and many health workers complained that if they find "too many new cases" it created problems for them because the districts with higher number of new cases were seen as "bad districts".

Over the years, WHO keeps on finding new goals for the leprosy programme but the confusion created by "leprosy elimination programme" continues to exist and to create problems.

Let me now touch briefly on the "Impact of Health for All" goal of WHO. 

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

I think that Alma Ata declaration was an impossible dream but it was an important ideal at that time because it was so inspiring. I would not call it a failure, I think that it was and continues to be one of the most successful ideals of Global Health. It helped in achieving some important services - from my personal experience of working in international health programmes, three elements are mentioned below as an example:

(1) Alma Ata declaration and health for all was not a single goal. It had many elements in it, and many of them were implemented successfully. For example, the essential medicines and the programmes for fighting against different infectious diseases, both of which had a huge impact.

(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.

I am sure that others can come up with many other examples of successful programmes which were inspired by the spirit of Alma Ata declaration. May be they were not fully achieved in 2000. Certainly, a large number of people still do not have access to essential health services, even in rich countries like USA. But a lot has been achieved since the Alma Ata declaration as shown by the evolution of global morbidity and mortality data across countries.

Impact of Other Factors

In terms of learnings from the Alma Ata declaration and the "Health for All by 2000" goal, for me a key take-away point is that health services and related goals can't be seen in isolation, they need to be looked at against the background of everything else happening in the world, including wars, famines and the role of international institutions.

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.

Conclusions

Pai's list of "global health failure" provoked me to write this post. As my explanations about leprosy and Alma Ata show, each of these points can be subjects of debates, and the answers may not always be negative. I think that similar provocative statements can be very useful to stimulate us to go deeper, study what had happened and reflect on the lessons we can learn from those expereinces.

A key point of Pai's article was that we don't learn from our failures. I am not sure if it is true. I think that the professionals involved in each of these "failures" must have debated and reflected on what happened and why for a long time, like we did about leprosy elimination. However, as time passes, all those discussions are forgotten and unless one takes the trouble of going back and reading through different point of views, the lessons learned can be easily lost.

(Note: an earlier version of this article was published in my blog in October 2021)