Institutional vision, keeping innovations simple, creating a learning culture by embracing feedback & failure and developing appropriate incentives hold the key, says the expert

05 August, 2020, Bengaluru: “Small is beautiful but big is necessary – that is the motto with scaling up health programmes,” said Dr. Richard Cash, Senior Lecturer on Global Health, Harvard T H Chan School of Public Health, drawing lessons from BRAC in a virtual lecture addressing students of IIM Bangalore’s one-year fulltime Master of Management Studies (Public Policy) – the Post Graduate Programme in Public Policy & Management (PGPPM) , today, as part of PGPPM’s event ‘Policy Speaks’, a Public Policy talk series.

BRAC is the world’s largest NGO that began operations in 1972 in post war Bangladesh to work with the poor to bring about a change in the quality of life.

Dr Cash’s 45-minute talk was titled, ‘From One to Many: Scaling Up Health Programs and Using Incentives Appropriately – The BRAC Experience’.

Recalling his visit in January 2020 to St. John’s Hospital, Dr Cash said he was glad to be back in Bangalore albeit online! 

To the students participating in the lecture, Dr Cash said: “There will always be tension between strategy and implementation so you’ve got to be flexible,” adding that government is critical in scaling up environment.

“It’s important to have pilot programs based on research and train workers before a pilot project,” he said, listing challenges and solutions drawn from BRAC’s Directly Observed Therapy (DOTS) for TB treatment. 

“Innovation, in BRAC’s DOTS programme, was in the form of introducing financial bonds given by patients, returned on completion of treatment but forfeited due to non-compliance,” he explained, pointing out that involvement of community health workers who got incentives for finding cases and completing treatment, a reliable backup healthcare system, frequent supervision and excellent management and availability of external technical assistance had led to the success of the model, which was then extended to other fields like microfinance, agriculture etc.

In the context of drawing lessons from BRAC’s diarrhoea programme, also in post war Bangladesh, he spoke of how mothers were taught, in their homes, to make ORT by female community health workers (using easily available ingredients in every home -- a pinch of salt and a scoop of ‘gud’ or jaggery in a seer of water) and how simple innovations like a cholera cot (with a sleeve that goes into a bucket to enable evacuation, measurement and replacement of lost fluid) to dramatically keep mortality down.

“Trust was built by the workers tasting the ORT themselves first,” he said, observing how this small act helped dispel myths that the community workers were propagating family planning! “The workers were evaluated on lessons learnt by the caregivers/ mothers. They were then paid on a pro-rata basis. This helped us assess what the mothers had learnt and what the workers should be paid. This message was so effective that 10 years later, the message was remembered and shared.”

Dr. Cash is the senior editor of ‘Casebook on Ethical Issues in International Health Research’, a WHO publication. Scaling up health programs is a major interest and he is the senior editor of ‘From One to Many: Scaling Up Health Programs in Low-Income Countries’. He has also documented the scaling up of the BRAC ORT program in ‘A Simple Solution’ and as a member of the BRAC Health Group, he and his colleagues have documented the BRAC TB DOTS program in ‘Making Tuberculosis History: Community-Based Solutions for Millions’. In 2006, he was the recipient of the Prince Mahidol Award and in 2011 he received the Fries Prize for Improving Health.

Dr Cash’s lecture was followed by a Q&A session that covered a spectrum of issues, including ways of motivating medical practitioners at the frontline, the effect of the fear caused by COVID-19 on mortality in diseases like TB in countries like India, and more.