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Jamison DT, Breman JG, Measham AR, et al., editors. Priorities in Health. Washington (DC): World Bank; 2006.

Cover of Priorities in Health

Priorities in Health.

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Former Secretary of Health, India

Priorities in Health is the companion volume to the second edition of Disease Control Priorities in Developing Countries (DCP2), a successor to the first edition (DCP1) published in 1993, but with a vastly expanded mandate. DCP1 proved to be a highly influential document in shaping health policies globally. The World Bank's (1993) path-breaking publication World Development Report 1993: Investing in Health, which incorporated DCP1's main concepts and messages, became the standard reference for health policy makers worldwide and even today continues to enjoy that status.

In India, the impact was dramatic, and I was greatly privileged to be in a position to manage and oversee the transition to greatly improved implementation of public health interventions in terms of both coverage and effectiveness. A serendipitous set of circumstances facilitated this, namely: an unprecedented fiscal and balance of payments crisis that compelled India to seek structural adjustment lending from the International Monetary Fund and the World Bank and resulted in severe fiscal compression; a shift in World Bank lending policies whereby the International Development Association was to emphasize social sectors; a paucity of health and education projects in the pipeline to use the highly concessional International Development Association allocation at a time when India was experiencing a severe foreign exchange crunch; and finally, an extraordinarily sympathetic and supportive team at the World Bank's India desk.

We became aware of DCP1's main concepts well before its publication by means of a seminar at Delhi's All India Institute of Medical Sciences in early 1992, at which Dean Jamison and his colleagues presented the main findings of DCP1 and the World Development Report 1993, including the concepts of disability-adjusted life years, burden of disease, epidemiological transition, and cost-effectiveness analysis as a tool for priority setting. These concepts provided a completely new way of determining priorities objectively based on evidence and economic analysis. Despite some initial and understandable skepticism about the methodologies and the estimates, the overall response was highly favorable.

At the same time, the World Bank was looking for objective criteria for identifying projects in the health sector. A commonality of approach developed between the World Bank and the Ministry of Health to use DCP1 techniques, which led to the revamping and scaling up of all major disease control projects in record time—particularly those against leprosy, blindness, tuberculosis, and malaria—in addition to new initiatives for dealing with the emerging threat of HIV/AIDS. Simultaneously, projects for system strengthening were also undertaken in several states to improve capacity. As a result, the developmental outlays for the Department of Health rose more than 5-fold and the external component rose more than 25-fold between 1990–1 and 2001–2 (India Health Report 2003), which not only increased available financial resources beyond anyone's expectations, but also completely changed how projects were formulated and implemented. This is a success story of which both the Indian government and the World Bank can legitimately be proud, that is, the contribution of DCP1 to channeling additional resources to cost-effective interventions to deal with the conditions responsible for a major share of the burden of disease.

Covering New Ground

DCP2 is a much more comprehensive, and indeed ambitious, effort. It goes well beyond updating the technical content, burden of disease, and cost-effectiveness estimates of DCP1. It covers new ground by examining important, complex areas, such as the delivery, management, and financing of health care and health research. It clearly recognizes that objective priority setting is only the first step: identified interventions have to be delivered to the targeted population efficiently to derive the full benefits of cost-effectiveness exercises; individual health interventions are rarely effective in isolation; and not only must the entire health system perform well to achieve positive outcomes but so do such related sectors like nutrition, drinking water, sanitation, and education. Raising the capabilities of the whole system along with establishing close linkages with other players is the key to success.

Presenting Leading Experts

DCP2 assembled an impressive array of the world's leading experts on health-related disciplines as contributors and is thus a treasure house of the latest knowledge, technical information, and international experience along with expert analyses on a multitude of health-related subjects. It should therefore legitimately expect to be an influential publication and a standard reference for health professionals and policy makers.

Promoting Effective Decision Making

DCP2 has the potential to contribute significantly to global health by promoting evidence-based and better-informed decision making at all levels. It comes at a particularly opportune time for my country, India, where for the first time since independence, the government is committed to giving high priority to health and raising public health expenditure from the current level of less than 1 percent to 2 or 3 percent of gross domestic product. DCP2 could therefore have a far greater impact than its predecessor, not only in the rational allocation of additional resources, but also in revitalizing and upgrading the public health delivery system, which has been performing poorly in much of the country.

Explaining Mortality and Morbidity Measurement

The Disease Control Priorities Project has also resulted in a separate book, the Global Burden of Disease and Risk Factors, which summarizes the concepts and estimates of the burden of disease and the attribution of this burden to several major risk factors. This volume is a definitive explanation of how mortality and morbidity are measured, including health damage such as stillbirths, which were not previously included in estimates of the global burden of disease, and of how these losses are combined into overall measures of health status. The book also provides estimates of how mortality has changed over time.

Highlighting Critical Issues

DCP2 highlights some critical issues that are widely recognized, but are often inadequately addressed in the international health literature. First and foremost, it recognizes equity as a key objective of health policy. The concern for equity arises not merely from a moral or human welfare standpoint, but also from the recognition of the critical role of health in alleviating poverty. Second, it clearly states that "unless equity considerations become part of policy making and of monitoring outcomes, interventions may widen instead of narrowing equity gaps." The book rightly attributes much of the progress in global health to technical progress in its broadest sense and the current glaring disparities in health status between and within countries to uneven application of this knowledge. The greatest challenge before the international community is thus "assuring that the benefits of technical progress are shared quickly and effectively on a global scale." A more forceful or clearer presentation of the case for equity would be hard to find.

Combining Balanced Views and Practical Approaches

Another quality that stands out in DCP2 is its total freedom from ideological bias along with a highly pragmatic approach. This results in the complete absence of prescriptive preaching and a refreshing open-mindedness. It clearly recognizes that socioeconomic, cultural, and governance diversities make a "one size fits all" solution to complex global health issues impossible. It therefore attempts to pool all relevant knowledge and lessons drawn from international experience to enable policy makers to make well-informed decisions suited to their particular situations. Another feature is that unlike many other publications, it takes a balanced view between the relative importance of mobilizing resources and of using them effectively and efficiently. Similarly, it exhibits a refreshing even-handedness in dealing with the responsibilities of the donor community and those of the developing countries themselves. The clear message is that while the rich countries should greatly step up their assistance, the poor countries must put their own houses in order to make good use of the money. While enlightened self-interest is necessarily the main motivation for donor support, a marked improvement in the quality of aid utilization would undoubtedly contribute significantly to improving the aid climate.

Offering a Comprehensive Array of Information

DCP2 is a voluminous, well-researched publication divided into 73 chapters, which might not be easy reading for lay readers. Even academics and health professionals may not be equally interested in all the subjects covered and may prefer to read selectively. The audience for DCP2 is intended to be wide: from academics and health professionals to health policy makers and program managers. Indeed, to derive the maximum benefits, the net would need to be cast wider to include the media, political parties, legislators, and the informed lay public. How often have we lamented that the lack of political will has been responsible for the neglect and failure of many health initiatives in the developing countries? Similarly, the lack of response from donor countries to admittedly deserving causes is often attributed to apathy and indifference to the problems of the poor among the populations of the rich countries.

Presenting DCP2's Content Succinctly

In democratic societies in both the industrial and developing countries, public opinion plays a critical role and needs to be systemically mobilized. Key messages therefore have to reach the media and lay readers on a wide scale to generate general awareness of and informed debate on key global health issues. We needed a companion volume that distills the essence of DCP2 into a succinct, lucid, and easy-to-read document. Priorities in Health addresses this need admirably. If the work of DCP1 became better known through the World Development Report 1993, this companion volume is the instrument for wide dissemination of DCP2. In barely 200 pages, it brings out clearly, in readable prose unencumbered by technical jargon and an overload of statistics, the essence of the entire document. It also opens a window to the main document for those interested in particular aspects to encourage them to read the relevant chapters. It can be read by busy policy makers during the course of a long flight. It is my sincere hope that Priorities in Health will be widely read in both developed and developing countries and that its messages will be actively debated to derive the maximum advantage from this magnificent effort. I consider Priorities in Health as a must-read for all those interested in health and related sectors.

Copyright © 2006, The International Bank for Reconstruction and Development/The World Bank Group.
Bookshelf ID: NBK10251
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